THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


^^3 


TREATISE 


THEEAPEUTICS 


TKANSLATED    BY    D.  F.  LIXCOLX,  M.D.,  FROM  FEENCTT  OF 


A.    TEOUSSEAU 

Professor  of  Therapeutics  in  the  FacitU>/  ofJledi- 
cijie  of  Pari"  :  PInjrsician  to  the  Hotel  Dieic ; 
Member  of  the  Academy  of  Medicine  ;  Com- 
mander of  the  Leffion  of  Honor ;  Ex-repre- 
gentatire  of  the  People  in  the  Constituent 
Assembly,  etc. 


11.    PIDOUX 

Member  of  the  Academy  of  Medicine ;  Honor- 
ary Physician  to  the  Huspitals :  Inspector 
of  Eaux-Bonnes;  Honormu  J'resident  of 
the  Societe  Ue  Therapmtlque ;  Honorary 
Member  of  the  Royal  Belgian  Academy  of 
Medicine,  etc. 


NINTH    EDITION 

REVISED  AXD  EXLARGED,  WITH  THE  ASSTSTAXCE  OF 
CONSTANTINE    PAUL 

Professeur  Agrege  in  the  Faculty  of  Medicine  of  Paris  ;  Physician  to  the  Hopita',  Saint-Antoine  ; 
Secretarie  General  of  the  Socieli  de  Therapentique. 


Volume   I. 


NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

27  Geea-t  Jones  Street 
1880 


Copyright,  1S60,  by 
WILLIAM    WOOD   &   COMPANY. 


Trow's 

painting  and  bookbinding  company, 

201-213   Kdst  \-2.th  Street, 

NKW  YOKK. 


Bw»edical 
lArary 

we 

CONTENTS 


CHAPTER  I. — Reconstituents. 

PAGE 

Iron 1 

Tonic  treatment  in  general 29 


CHAPTER  II.— Astringents. 

Tannin 73 

Oak  bark,  tan 77 

Walnut 78 

Uva  ursi,  comfrey,  whortleberry 80 

Catechu 81 

Kino 81 

Rhatany 83 

Paulliuia,  or  guarana 8(5 

Creasote , 87 

Lead 89 

Alum 94 

Bismuth   99 

Tonic  astringent  treatment  103 


CHAPTER  III.— Alteratives. 

Mercury 115 

Iodine .• 137 

Iodoform 1 59 

Cod-liver  oil 101 

Arsenic , 169 

Gold 185 

Platinum 188 

Silver 189 

Soda 193 


706057 


IV  CONTENTS. 

PAGE 

Borax 198 

Lime 199 

Baryta 203 

Lithia 203 

Ammonia  and  comi^ounds 204 

Chloride  of  sodiuiu 210 

Alterative  treatment  in  general 213 


CHAPTER  IV.— Irritants. 

Potassa 225 

Soda 228 

Silicate  of  sodium 229 

Lime  229 

Ammonia 231 

(Jompouuds  of  ammonia 236 

Chlorine 238 

Hydrochloric  acid 240 

Alkaline  chlorides 241 

Silver 243 

Sulphuric  acid 246 

Zinc 247 

Copper 251 

Antimony 252 

Mustard 253 

Cantharides 260 

Ranunculaceas 269 

Euphorbiacea3 270 

Pitch— Turpentine 272 

•Resin  of  thapsia  garganica 272 

Substitutive  irritant  treatment 274 

Transpositive    "              "              285 

Spoliative          "              "             296 

Excitative          "             "              • 301 


THEKAPEUTIOS. 


CHAPTER  I. 

EECONSTITUENT  KEIvIEDIES. 
Iron. 

Chlorosis. 


Tx  order  to  form  a  just  idea  of  the  action  of  the  ferruginous  drugs,  it 
is  necessary  to  consider  the  disturbances  produced  in  the  system  by  modi- 
fications in  the  crasis  of  the  blood. 

A  number  of  disturbances  occur  after  a  full  bleeding,  no  doubt  owing 
to  the  fact  that  the  organs  no  longer  receive  an  amount  sufficient  for  the 
discharge  of  their  functions.  In  proportion  as  the  loss  of  blood  is  re- 
paired, these  disturbances  cease.  But,  if  the  bleedings  are  repeated  so 
often  that  the  blood  cannot  be  renewed,  if  the  supply  of  nutriment  is  not 
sufficiently  rich  to  furnish  materials  for  such  renovation,  or  if  a  malady, 
unknown  in  its  essence  but  very  common,  blanches  the  blood  to  an  extent 
even  greater  than  the  most  abundant  bleeding  will  cause,  a  condition  of 
the  system  supervenes  which  is  known  in  women  by  the  name  of  chlorosis, 
and  in  men  is  termed  anaemia. 

Chlorosis  is  almost  always  spontaneous.  Anfemia  is  almost  always 
secondary. 

It  is  not  easy  to  say  why  chlorosis  is  the  almost  exclusive  property  of 
vFomen;  but  every  one  knows  that  it  is  extremely  rare  to  find  a  young 
man  chlorotic. 

It  has  been  supposed  that  this  fact  might  be  explained  by  the  differ- 
ence between  the  composition  of  the  blood  in  the  two  sexes.  Analysis 
proves  that,  in  general,  the  blood  of  a  healthy  woman  contains  a  little 
less  of  the  globules*  than  that  of  a  man  in  good  health.  But,  admitting 
that  this  difference  is  not  without  some  influence,  it  is  more  rational  to 
suppose  that  the  real  cause  of  this  remarkable  pathological  fact  resides  in 
conditions  inherent  in  the  sex. 

The  analysis  of  MM.  Andral  and  Gavarret  demonstrate  that  in  1,000 
grammes  of  normal  blood  we  find,  on  an  average,  137  grammes  of  blood- 


Z  THERAPEUTICS. 

globules;  while  in  the  case  of  chlorotic  persons  the  amount  may  fall  to 
38,  the  quantity  of  fibrin  remaining*  nearly  the  same  as  in  women  in 
health. 

These  analyses  account  for  the  pallor  and  the  liquidity  of  the  blood  of 
chlorotic  patients,  and  perhaps  for  the  greater  part  of  the  singular  symp- 
toms of  which  they  complain.  One  can  see  how  the  blood,  robbed  of  a 
part  of  its  stimulant  principles,  ceases  to  be  fit  to  modify  the  organs,  and 
that  numerous  functional  troubles  are  the  result. 

The  muscles  of  animal  life  lose  color,  become  atrophied  and  relaxed; 
hence  arises  difficulty  and  slowness  of  motion.  The  mviscles  of  organic 
life  share  in  the  same  changes;  hence,  flaccidity  of  the  heart,  difficult 
circulation,  sluggishness  of  the  stomach,  constipation,  flatulence.  Final- 
ly, the  blood  which  reaches  the  nervous  centres,  the  glands,  and  tlie 
membranes,  no  longer  possessing  its  natural  qualities,  these  organs  can 
no  longer  exercise  their  functions  as  in  their  natural  state. 

If,  then,  we  were  to  restore  to  the  blood  the  principal  elements  which 
it  lacked,  we  should  make  it  again  capable  of  exerting  its  regular  inilu- 
ence  upon  the  economy.     This  end  is  attained  by  Iron. 

How  does  iron  act  in  chlorosis  ? 

Upon  this  point  there  are  two  very  distinct  opinions. 

The  majority  at  the  present  day  believe  that  iron,  when  absorbed, 
passes  directly  into  the  blood,  is  there  precipitated  in  the  form  of  oxide, 
restores  to  it  immediately  the  principles  which  are  wanting,  and  makes 
the  blood  a  reparative  fluid  at  once. 

Others  attribute  to  this  remedy  a  purely  tonic  action,  in  virtue  of 
which  the  digestive  and  nervous  functions  are  so  influenced  as  to  make 
innervation  and  nutrition  more  perfect — the  organic  restoration  taking 
place  indirectly,  by  means  of  this  tonic  action. 

In  support  of  this  opinion  we  are  able  to  quote  the  authority  oi 
Claude  Bernard  ("Legons  faites  au  College  de  France,"  published  in 
the  Union  medicale,  1854). 

"  The  real  question,"  says  this  eminent  physiologist,  "  is  not,  whether 
iron  cures  chlorosis,  but,  in  the  first  place,  whether  chlorosis  is  due  to  the 
absence  of  iron,  and  if  iron  given  as  a  medicine  will  fill  the  place  of  that 
which  is  wanting. 

"  Certain  authors  have  claimed  that  the  proportion  of  iron  in  the  blood 
of  chlorotic  jicrsons  was  lessened,  but  they  have  not  proved  the  fact 
chemically.  Those,  on  the  contrary,  who  have  made  the  analysis,  have 
found  that  the  amount  of  iron  was  the  same  in  chlorosis  as  in  other  cases. 
It  is  true  that  in  this  disease  the  amount  of  globules  is  diminished. 

"  Let  us  suppose — as  is  probable — tliat  there  are  about  6  grammes 
of  iron  in  the  mass  of  the  blood,  and  that  in  chlorosis  the  blood  loses  '■) 
grammes.  If  all  the  iron  which  is  given  were  absorbed,  we  should  soon 
see  the  blood  regaining  this  amount;  but  we  know  that  it  requires  at 
least  a  month,  and  often  much  longer,  to  cure  the  disease,  in  spite  of  the 
masses  of  iron  which  are  swallowed." 


EECONSTITUENT    REMEDIES.  3 

Another  difficulty  liere  meets  us:  we  cannot  positively  prove  the  ab- 
sorption of  iron  in  the  stomach  or  intestines.  Bernard  injected  iron-fil- 
ings— the  lactate,  etc. — into  the  stomach,  but  was  never  able  to  discover 
in  the  blood  of  the  portal  vein  a  larger  quantity  than  is  usual. 

"But,"  continues  Bernard,  "since  iron  exists  in  the  food,  a  certain 
combination  may  be  required  in  order  to  effect  absorption." 

There  is,  however,  one  fact  which  is  positive  and  perfectly  demon- 
strated: the  salts  of  iron  (adds  Bernard)  exercise  a  special  action  upon 
the  gastric  mucous  membrane.  Every  portion  of  the  membrane  which  is 
touched  by  them  assumes  a  more  active  circulation.  Iron,  therefore,  is  a 
direct  excitant. 

In  conclusion,  Bernard  puts  this  question: 

"  May  not  chlorosis  be  due  to  a  faulty  digestion  ?  May  not  iron  re- 
establish these  disturbed  functions  by  the  excitation  it  produces  ?  " 

It  is  possible  that  Bernard  has  not  said  the  last  word  upon  this  ques- 
tion. But  we  see  that  the  data  furnished  by  chemistry  are  far  from  satis- 
fying him;  and,  if  he  has  not  yet  solved  this  grave  difficulty,  he  at  least 
has  the  merit  of  placing  us  on  the  road  to  its  solution. 

Two  points  remain  to  be  settled:  on  the  one  hand,  the  conditions 
which  favor  the  absorption  of  a  certain  quantity  of  iron  by  the  stomach 
are  to  be  determined,  for  such  absorption  seems  to  us  unquestionable, 
though  it  be  not  fully  demonstrated  by  chemistry;  on  the  other  hand, 
the  mysterious  combination  must  be  ascertained,  which  enables  the  mi- 
nute and  imperceptible  absorption  to  take  place.  And  finally,  we  must 
discover  the  secret  of  the  mechanism  by  which  the  atoms  of  iron,  drifting 
through  the  circulation,  revivify  the  impoverished  and  altered  globules, 
and  build  up  the  body. 

The  facts,  or  such  as  seem  best  demonstrated  at  present,  are  as  fol- 
lows: 1.  The  blood  of  chlorotic  women  contains  less  of  the  globules  than 
is  the  case  in  well  women.  2.  Under  the  use  of  the  chalybeates,  the  blood 
usually  recovers  quickly  the  cruor  and  the  globules  which  it  had  lost.  3. 
Iron  given  to  chlorotic  patients  seems  to  have  two  methods  of  action,  dis- 
tinct, but  equally  necessary.  For,  firstly,  it  acts  as  a  tonic  and  direct  ex- 
citant of  the  stomach,  or  (if  we  prefer  the  expression)  as  a  special  modifier 
of  the  peptic  sense;  and  secondly,  a  part  of  the  iron  is  very  probably  dis- 
solved in  the  gastric  juice  and  absorbed,  coming  directly  in  contact  with 
the  inner  coats  of  the  vessels;  while,  by  virtue  of  an  action  which  we  call 
dynamic  or  vital,  without  attempting  to  examine  or  to  define  it,  the  med 
icine  by  slow  degrees  places  the  impaired  functions  of  h^ematosis*  upon 
a  normal  footing.  It  is  the  combination  of  these  two  actions  that  recon- 
structs the  blood-globules,  and  finally  cures  chlorosis.     Such,  in  our  opin- 


*  We  refer  especially  to  that  action  of  vital  chemistry  which  taken  place  in  the 
great  circulatory  system  :  an  important  action,  too  little  noticed  by  our  physiologists. 
which  commences  in  the  left  cavities  of  the  heart,  is  continued  in  the  entire  circuit  of 
the  blood,  and  is  perfected  in  the  capillary  extremities. 


4  THERAPEUTICS. 

ion,  is  the  true  part  played  by  iron  in  chlorosis;  such,  at  least,  is  the  in- 
terpretation which  seems  to  us  most  rational  and  acceptable,  drawn  from 
the  most  recent  researches  in  organic  chemistry  and  experimental  physiol- 
ogy, and  in  harmony  with  good  sense  and  tradition. 

Chlorosis,  till  very  lately,  was  a  triumph  for  the  defenders  of  the 
chemical  theory.  "  Evidently,"  said  they,  "  this  disease  is  due  to  a  di- 
minution of  the  iron  in  the  blood.  By  giving  iron,  we  restore  the  princi- 
ple which  is  wanting,  and  the  disease  is  cured.  What  is  more  simple, 
clear,  and  decisive  ?  " 

Unfortunately,  the  two  bases  of  their  theory,  supposed  to  be  unassail- 
able, have  been  shaken  by  experiment.  And  we  may  add  that,  in  the  recent 
long  discussion  in  the  Academy,  the  chemists  of  most  authority  offered 
no  new  argument  in  support  of  their  theory.  The  result  of  this  debate 
and  the  general  tendency  of  opinion  show  that  chlorosis  will  soon,  like 
the  rest  of  pathology  and  therapeutics,  be  surrendered  to  the  vitalists. 

Chlorosis,  we  do  not  hesitate  to  say,  rules  the  pathology  of  woman; 
and  the  physician  who  cannot  recognize  this  affection  in  its  various  forms- 
will  often  fail  in  treating  this  class  of  diseases.  M.  Nonat  infers  from 
the  frequency  of  abnormal  bruits  in  the  neck  of  children  that  eight  in  ten 
are  chlorotic  (Acad,  de  med.,  18  Septembre,  1860).  This  is  hardly  the 
place  for  a  pathological  dissertation;  but,  as  we  entertain  certain  views 
upon  chlorosis  wliich  are  not  generally  admitted,  we  shall  have  to  place 
the  reader  at  our  own  point  of  view  by  an  explanation ;  it  would  other- 
wise be  impossible  for  him  to  understand  the  close  connection  between 
affections  which  seem  very  distinct,  but  which,  recognizing  the  same 
cause,  obey  the  same  therapeutical  agency — that  of  iron. 

In  its  most  marked  and  unmistakable  form,  chlorosis  is  accompanied 
by  the  following  symptoms: 

General  loss  of  color  of  the  skin  and  the  mucous  membranes;  slight 
emaciation,  puffiness  of  the  face  and  the  lower  extremities. 

Nervous  condition,  hysteria,  melancholia,  mobility,  muscular  debility. 

Neuralgic  pains,  usually  of  irregular  type. 

Increase  or  diminution  of  the  volume  of  the  heart;  ventricular  impulse 
sometimes  more  energetic,  sometimes  more  feeble  than  in  a  condition  of 
health  ;  bruit  de  souffle,  generally  soft,  with  the  first  sound  of  the  heart; 
second  sound  sometimes  sharp;  various  souffles  in  the  great  arteries,  espe- 
cially the  carotids,  subclavians,  etc.,  and  in  the  veins  of  the  neck. 

Pulse  more  frequent  than  in  health;  febrile  heat,  dryness  of  skin, 
thirst. 

Panting  upon  the  slightest  movement;  palpitations. 

Dyspepsia,  pyrosis,  depraved  appetite,  gastralgia,  sometimes  vomiting, 
habitual  constipation,  diarrhoea  when  the  disease  has  lasted  a  great 
while. 

Menstruation  painful,  irregular,  scanty,  wanting  in  color,  absent; 
leucorrhoea;  menorrhagia;  sterility. 

Such  is  the  picture  (or  the  outline)  of  chlorosis.     Under  the  influence 


EECONSTITUENT    KEJVIEDIES.  5 

of  ferruginous  preparations,  this  frightful  array  of  symptoms  usually  dis- 
appears with  rapidity. 

"  How  should  iron  be  given  in  chlorosis,  in  what  dose,  and  how  long  ?  " 
These  questions  have  hardly  been  touched  by  therapeutists,  and  few 
practitioners  have  taken  the  trouble  to  study  deeply.  We  except  Syden- 
ham, who  has  given  the  principles  of  good  treatment,  but  has  not  suffi- 
ciently insisted  on  certain  minutiae,  of  the  great  importance  of  which  we 
are  convinced  by  long  experience. 

The  slightly  soluble  preparations  ought  to  be  used  in  general  at  the 
beo-inning  of  treatment.  Iron-filings,  aperient  crocus  martis,  hydrate  of 
peroxide  of  iron,  occupy  the  first  rank.  They  are  given  in  powder  in  a 
spoonful  of  broth,  or  in  preserves,  morning  and  evening,  at  the  two  chief 
meals,  in  doses  of  from  5  to  15  centigrammes  (-8  to  2-d  grains).  If  this 
dose  is  easily  borne,  it  is  gradually  increased,  until  by  degrees  the  quan- 
tity of  one  or  two  grammes  (15 — 31  grains)  at  each  meal  is  reached.  It 
is  essential  that  the  remedy  should  be  taken  at  the  beginning  of  the  meal, 
for,  if  taken  in  the  morning  fasting,  as  is  sometimes  ordered,  the  patient 
feels  a  weight  at  the  stomach,  and  a  great  sense  of  disgust,  and  loses 
appetite. 

There  is  another  reason  for  giving  it  at  meals,  for  it  is  only  at  those 
times  that  the  gastric  fluids  contain  a  sufficient  quantity  of  acid,  while,  a 
little  before  eating,  they  are  slightly  acid  or  neutral,  and  sometimes  even 
alkaline.  If  pyrosis  exists,  the  best  time  for  taking  iron  would  be,  for 
obvious  reasons,  the  interval  between  meals. 

If  slightly  soluble  preparations  are  well  borne,  and  if  improvement 
does  not  occur,  we  must  give  soluble  preparations,  and  in  particular  the 
tartrate  of  iron  and  potassium,  given  in  pills  or  in  gaseous  waters.  For 
certain  women,  we  prescribe  the  tartarized  tincture  of  iron,  ferrated 
water,  chalybeate  wine,  etc. 

This  treatment  is  not  to  be  interrupted  at  the  monthly  period,  and  is 
to  be  continued  till  all  the  symptoms  of  chlorosis  have  disappeared.  We 
then  cease  giving  it;  a  month  later  we  resume  it,  and  continue  it  for  two 
or  three  weeks.  Then  we  leave  an  interval  of  two  months;  then  we  give 
the  iron  for  a  fortnight;  and  this  plan  is  to  be  followed  up  for  five  or  six 
months,  for  if  it  be  easy  to  cure  chlorosis,  it  is  hard  to  cure  it  in  such  a 
way  as  to  be  secure  against  relapses,  and  relapses  are  always  to  be  feared 
if  we  suspend  the  use  of  iron  suddenly. 

Chlorosis  is  considered  by  some  pathologists  as  a  very  slight  malady; 
but  we  consider  it  a  very  serious  affection  which  many  women  never  for- 
get as  long  as  they  live,  being  either  in  continual  danger  of  a  relapse,  or 
else  (as  is  more  common),  in  continual  trouble  from  some  of  the  functional 
disturbances  which  come  in  the  train  of  chlorosis,  although  apparently  in 
health. 

It  is  also  a  fact  which  is  observed  as  one  grows  older  in  practice,  that 
iron,  after  having  relieved  the  worst  symptoms,  sometimes  becomes  all  at 
once  impotent.     The  remedy,  in  such  cases,  acts  with  a  certainty  inversely 


b  THEKAPEUTICS. 

proportioned  to  the  duration  of  the  complaint  and  the  number  of  the 
relapses. 

Some  patients  have  a  singular  experience.  For  a  while  they  bear 
large  doses  of  iron  and  improve  rapidly,  but  suddenly  they  find  the 
remedy  disagrees  with  them,  and  seem  to  be  in  a  sort  of  state  of  satura- 
tion. The  ph^'^sician  should  then  pause,  and  begin  again  according  to  the 
method  which  we  have  mentioned  above. 

Evident  as  may  be  the  indication  for  the  use  of  iron,  it  is  not  alwavs 
easy  to  fulfil  it.  The  condition  of  the  stomach  and  intestines — a  suscep- 
tibility which  cannot  be  foreseen — may  form  a  great  obstacle.  Yet  we 
ought  to  keep  the  aim  constantly  in  view,  and  to  persevere  for  weeks  or 
months  in  modifyiiig  this  irritability,  or  accustoming  the  system  to  the 
effects  of  iron. 

Nevertheless,  when  the  signs  of  chlorosis  exist,  we  must  suspect  a 
woman  who  bears  iron  badly,  for  such  intolerance  is  usually  the  sign  of  a 
bad  diathesis. 

When  chlorotic  patients  are  disposed  to  diarrhoea,  iron  ought  not  to 
be  given  at  first,  and  the  soluble  forms  should  never  be  prescribed.  For 
a  time  we  should  give  subnitrate  of  bismuth,  Colombo,  diascordium,  j)lios- 
phate  of  lime,  in  the  dose  of  25  to  50  centigrammes  (3*8 — 7*7  grains)  at 
each  meal,  nitrate  of  silver  in  the  dose  of  1  to  5  centigrammes  {'15 — '77 
grain)  in  a  draught  taken  during  the  day,  to  check  the  diarrhoea. 

When  we  have  reason  to  suppose  that  the  gastric  irritability  is  quieted, 
we  give  at  first,  with  the  above,  small  doses  of  iron-filings,  or  of  any 
other  slightly  soluble  preparation,  gradually  increasing  the  propor- 
tion of  iron  until  it  is  borne  in  the  amount  of  1  or  2  grammes  (15  to 
31  gr.). 

When  there  exists  stubl)orn  constipation,  we  add  a  soluble  salt  (as  the 
tartrate  or  citrate)  of  iron,  in  pill,  to  aloes,  and  a  little  belladonna ;  giv- 
ing per  diem  5 — 10  centigrammes  of  aloes  ("7  to  1'5  gr.),  one  or  two  cen- 
tigrammes of  extract  of  belladonna  ("15  to  '3  gr.),  and  75  centigrammes, 
1  gramme,  2  grammes  of  the  iron  salt  (12,  15,  30  grains). 

Aloes  has  here  the  double  advantage  of  acting  as  a  laxative  and  as  an 
emmenagogue.  It  follows  that,  if  menorrhagia  exists,  as  it  often  does, 
aloes  must  not  be  given,  but  in  its  place  powdered  rhubarb,  or  (still  bet- 
ter) magnesia,  to  be  taken  before  bedtime. 

It  is  a  received  opinion  among  physicians,  that  chlorosis  is  confined 
to  young  girls„  febris  alba  virginum.  This  idea,  generally  received,  is 
false  in  every  respect,  and  it  daily  gives  rise  to  mistakes  which  have  a 
very  fatal  effect  upon  the  treatment.  Chlorosis  is  in  general  a  disease  of 
adolescence,  but  it  is  also  very  frequent  in  adult  life;  it  appears  in  women 
at  the  change  of  life;  and  we  have  seen  it  twice  at  a  later  period — in  a 
woman  of  fifty-two,  and  in  another  of  fifty-seven,  both  of  which  cases 
were  characteristically  marked,  and  were  easily  cured  by  iron. 

We  long  regarded  iron  as  a  harmless  agent,  which  it  was  not  easy  to 
abuse.      Now  that  we  have  grown  a  little  old  in  practice,  we  declare  that 


KECOISfSTlTUENT    REMEDIES.  7 

we  have  repeatedly  seen  patients  whose  death  seemed  to  us  due  to  the 
untimely  use  of  preparations  of  iron. 

It  is  easy  to  see,  a  priori,  that  by  increasing-  the  stimulant  properties 
of  the  blood  in  a  healthy  person,  we  predispose  him  to  diseases  to  which 
he  had  no  previous  tendency. 

It  is  also  easy  to  understand  how  a  woman,  whose  blood  has  lost 
three-quarters  of  the  normal  amount  of  globules,  may,  while  suliering 
from  the  accidents  which  belong  to  chlorosis,  enjoy  a  certain  immunity 
from  the  diseases  which  attack  by  preference  persons  whose  blood  is  rich 
in  these  elements. 

In  some  instances,  women,  though  strongly  predisposed  by  constitu- 
tion or  inheritance,  have  escaped  all  complaints  of  the  chest  for  several 
years,  while  in  a  chlorotic  condition;  but  when  subjected  to  treatment 
with  iron,  acute  phthisis  has  quickly  followed  the  cure  of  the  chlorosis. 

These  are  positive  facts,  and  they  have  been  so  often  repeated  in  our 
sight,  that  we  now  refuse  to  give  the  preparations  of  iron  to  chlorotic 
women,  if  they  have  previously  had  suspicious  symptoms  of  the  chest,  or 
have  tuberculous  parents.  In  these  cases  we  try  to  support  the  strength 
by  neurosthenic  tonics,  and  we  are  not  in  haste  to  use  iron,  which  often 
is  speedily  fatal. 

We  desire  not  to  be  understood,  however,  as  systematically  excluding 
the  preparations  of  iron  from  the  treatment  of  pulmonary  phthisis.  It  is 
important  to  draw  a  distinction.  We  confidently  state,  as  the  result  of 
many  observations,  that  iron  is  usually  injurious  in  the  first  period  of  this 
malady;  we  mean  when  the  development  of  the  tubercles  is  accompi;nied 
by  pronounced  phenomena  of  congestion  or  of  irritation  of  the  apparatus 
of  respiration  or  circulation,  as  haimoptyses,  rough  cough,  fever  with 
dryness  of  the  skin,  sharp  pains  in  the  chest,  etc.  In  these  conditions, 
iron,  often  given  as  an  article  of  routine  treatment,  on  account  of  the 
weakness  and  the  poverty  of  blood,  is  formally  contra-indicated,  as  is  the 
ronic  and  analeptic  regimen. 

But  at  a  later  stage  the  case  is  changed.  If  a  patient,  for  instance, 
has  been  weakened  by  repeated  or  abundant  hasmoptyses,  and  his  expec- 
toration, sweating,  diarrhoea,  etc.,  have  exhausted  him,  the  iron  prepara- 
tions will  then  be  properly  used,  to  give  a  little  vigor  to  the  languid 
digestive  and  assimilative  functions.  Unhappily,  however,  in  these  cases, 
iron  loses  a  great  part  of  the  wonderful  virtues  which  it  possesses  in 
chlorosis  and  in  accidental  anjemia  succeeding  sitnple  hiemorrhage.  But, 
while  it  accomplishes  nothing  against  the  tuberculous  diathesis  itself,  it 
is  sometimes  useful  by  helping  the  unhappy  patient  to  struggle  for  a 
time  with  the  cachectic  state,  which  is  more  injurious  to  him  than  the 
local  lesion. 

The  greatest  circumspection  must  be  used  in  these  cases.  Circum- 
stances may  seem  imperiously  to  demand  the  use  of  iron,  but  it  will  not 
always  be  well  borne,  and  in  general,  it  is  far  from  being  so  harmless  as 
many  practitioners    imagine.     These    remarks  apply   with  especial  force 


8  THERAPEUTICS. 

to  tuberculous  phthisis,  in  which  experience  has  shown  that  iron  gener- 
ally does  more  harm  than  good.  Phthisis  of  scrofulous  origin  differs 
from  this  in  the  slowness  of  its  course,  the  slighter  intensity  of  the  in- 
flammatory and  reactionary  symptoms,  and  especially  in  its  greater  toler- 
ance of  tonics  and  excitants.  Thus,  in  children  who  are  at  the  same  time 
lymphatic  and  strumous,  affected  with  caseous  pneumonia  and  tubercles 
in  the  mesenteric  glands,  it  is  not  uncommon  for  iron,  in  moderate  doses, 
to  improve  the  nutrition,  sustain  the  vital  resistance,  and  check  the  prog- 
ress of  the  malady  for  a  time. 

In  general,  as  we  said  above,  a  practitioner  ought  to  distrust  a  chloro- 
tic  patient  who  bears  iron  badly  at  the  outset  of  the  first  treatment,  or 
whose  condition  is  not  modified  by  a  proper  administration  of  it.  He 
should  infer  the  existence  of  some  latent  diathesis,  or  grave  organic  dis- 
ease, or  moral  affection,  holding  the  chlorosis  under  obstinate  control. 

The  tuberculous  diathesis  is  often  masked  under  the  form  of  chlorosis. 
The  physician  vainly  attacks  the  apparent  disease;  obstinate  gastralgia, 
continued  diarrhoea,  painful  palpitations  of  the  heart,  troublesome  op- 
pression, sanguine  congestion  of  the  face,  especially  at  evening  and  after 
eating,  are  produced  or  persist,  and  the  blood  is  slow  to  regain  the  glob- 
ules which  it  lacks;  happy  are  they  whose  blood  does  not  restore  itself  at 
the  physician's  will,  for  they  will  pay,  by  a  speedy  disorganization  of  the 
lungs,  for  this  momentary  hope  of  health. 

In  practice,  whenever  a  young  girl  has  some  symptom  of  chlorosis,  or 
mereh'  ana3mia,  iron  is  sent  for  in  haste.  A  commencing  phthisis  is  thus 
often  spurred  into  activity.  Doctor  Millet,  of  the  colony  at  Mettray,  has 
had  more  than  sixty  cases  of  phthisis  in  which  preparations  of  iron  have 
been  given  by  nuns  or  druggists,  to  the  great  injury  of  the  patients. 

A  cachexy,  which  completely  resembles  chlorosis,  is  often  associated 
with  albuminuria,  chronic  engorgement  of  the  liver  or  spleen,  or  a  valvu- 
lar lesion  of  the  heart.  Here,  at  least,  iron  does  no  harm;  it  is  even  of 
unquestionable  utility  in  the  treatment  of  the  antemia,  which  appears  to 
depend  on  hypertrophy  of  the  spleen  or  liver,  especially  when  these  lesions 
follow  intermittent  fevers,  and  are  not  accompanied  by  organic  lesion. 


Component  Elements  of  Chlorosis. 

The  group  of  symptoms  which  we  have  named  is  not  always  found 
combined  in  chlorosis;  most  frequently,  in  fact,  some  of  them  are  absent. 
To  use  the  happy  expression  of  Recamier,  the  symptomatic  phrase  is  in- 
complete; but  it  is  necessary  to  recognize  it  even  in  its  incompleteness, 
or  else  we  shall  fail  to  attack  the  root  of  the  malady,  and  shall  be  strug- 
gling with  a  mere  accident,  which  may  be  banished  for  a  moment,  but 
will  soon  return  with  equal  intensity  in  the  same  or  a  different  form. 

Paleness  of  the  blood,  and  of  the  skin  and  mucous  membranes,  may 
exist  alone  without  any  symptoms  besides  shortness  of  breath  and  disor- 


RECONSTITUENT    REMEDIES.  9 

dered  circulation.  This  form  is  the  simplest;  it  is  easily  recognized  and 
cured. 

But  quite  often  the  common  symptoms  of  chlorosis,  as  the  nervous 
symptoms,  indigestion,  menstrual  disturbances,  appear  together  or  sin- 
gly before  the  pallor  has  reached  its  maximum  ;  and  then  the  common 
run  of  doctors — men  who  require  all  the  elements  in  order  to  form  a  diag- 
nosis— fail  to  see  chlorosis,  which  really  exists. 

JVervoics  sym2)tot}is. — Women  are  often  attacked  by  hysteria,  by 
spasms,  after  great  losses  of  blood,  accouchement,  lactation;  so  are 
young  girls  at  the  beginning  of  chlorosis.  Tliese  nervous  troubles  easily 
yield  to  preparations  of  iron,  altliough  hysterical  convulsions  are  not  so 
easy  to  conquer  as  essential  spasms.  When,  however,  this  spasmodic 
condition  exists  in  a  vigorous,  high-colored  woman,  who  exhibits  none  of 
the  signs  of  chlorosis,  iron  increases  rather  than  diminishes  the  convul- 
sions. 

Neuralgias. — These  are  almost  a  constant  symptom  in  chlorosis;  of 
twenty  chlorotic  women,  nineteen,  perhaps,  will  have  neuralgia. 

The  disease  is  not  always  very  easy  to  recognize,  and  the  patient  and 
physician  may  both  be  deceived.  Women  complain  of  pain  in  the  head 
or  stomach,  in  the  side  or  legs,  etc.  A  superficial  examination  shows 
nothing  but  a  common  headache,  a  stomach-ache  analogous  to  tliat  which 
accompanies  difficult  digestion,  vague  pains,  attributed  to  fatigue  or  ex- 
haustion; but  when  they  are  examined  closely  their  neuralgic  nature  ap- 
})ears.  The  pain  in  the  head  occupies  the  brow,  the  temples,  the  region 
of  the  jaw,  the  teeth — in  a  word,  the  course  of  the  nerves  of  the  fifth  pair 
and  its  branches;  it  scarcely  ever  attacks  both  sides  at  once,  but  it  passes 
from  right  to  left,  or  remains  fixed  in  one  point.  All  at  once  it  shifts  its 
place  and  occupies  the  region  of  the  stomach,  then  it  leaves  the  stomach 
and  goes  to  the  intercostal  nerves,  to  the  sciatic,  or  some  of  its  branches, 
or  the  various  branches  of  the  lumbo-abdominal  plexus.  Then  the  ceph- 
alalgia reappears  at  the  moment  when  the  other  pains  cease. 

This  inconstancy  in  the  seat  of  pain  is  very  remarkable  and  very  com- 
mon ;  but  sometimes  the  neuralgia  affects  a  single  region,  the  head,  the 
stomach,  or  some  intercostal  nerves.  It  is  rarely  fixed  obstinately  in 
other  parts,  but  we  have  observed  it  in  the  nerves  of  the  heart,  the  cli- 
toris, the  superficial  cervical  plexus,  one  of  the  branches  of  the  bracliial 
plexus,  the  pharyngeal  plexus  (Tiirck  :  Arch,  de  vied.,  18G2);  but  these 
cases  are  rare. 

These  forms  of  neuralgia,  if  we  attend  closely  to  them,  are  rarely  seen 
in  men,  being  confined  almost  wholly  to  feeble  women,  with  distinct 
symptoms  of  chlorosis,  past  or  present. 

When  neuralgia  is  the  leading  feature,  whether  occupying  the  head 
or  the  stomach,  it  is  usually  cured  by  iron,  though  less  easil}^  than  simple 
chlorosis. 

Temporo-facial  neuralgia  (called  so  improperly  tic  douloureux — a 
name  which  should  be  reserved  for  spasmodic  neuralgia)  has  been  treated 


10  TIIEKAPEUTICS. 

with  advantage  bv  large  doses  of  subcarbonate  of  iron.  Hutchinson, 
who  may  be  regarded  as  the  author  of  this  method  (Benj.  Hutchinson: 
''  Cases  of  Neuralgia  Spasmodica,"  London,  1812),  has  observed  nearly 
two  hundred  cases  of  cure.  He  gives  from  2  to  4  grammes  (30 — 60  grains) 
of  subcarbonate  mixed  witli  honey,  three  times  a  day.  Wittke  has  ob- 
tained the  most  happy  results  from  it,  in  the  dose  of  1^  grammes  (22 
grains)  with  |-  gramme  (4  gr.)  of  cinnamon,  three  times  a  day  (Huf eland: 
Journal,  1828,  Vol.  4).  The  English  journals  are  full  of  similar  observa- 
tions. M.  Caulet  reports  remarkably  rapid  cures  with  the  waters  of 
Forges  (Caulet:  llemarques  sur  Paction  sedative  immediate  des  sources 
ferrugineuses  de  Forges-lcs-Jiaux,  Seine-Inferieure,  18G7). 

Having  made  a  great  many  experiments  in  the  therapeutic  use  of 
iron,  especially  the  subcarbonate,  and  in  cases  of  neuralgia,  we  can  easily 
see  the  cause  of  the  differences  in  opinion  which  exist.  When  given  to 
chlorotic  women,  or  in  cases  of  neuralgia  in  incipient  chlorosis,  it  has 
usually  succeeded  ;  but  if  given  to  men,  or  to  women  who  were  not 
chlorotic,  it  has  usually  failed.  These  results  may  be  formulated  by  say- 
ing that  the  beneficial  effects  of  preparations  of  iron  in  neuralgia  are 
entirely  due  to  the  fact  that  the  disease  usually  depends  on  chlorosis, 
which  is  curable  by  iron. 

The  cure  of  neuralgia  by  iron  is  not  a  rapid  one,  but  requires  a  week, 
a  fortnight,  a  month,  or  longer,  in  order  to  be  complete.  If  the  face  is 
affected  we  always  employ  Hutchifison's  method  to  quiet  the  accesses,  and 
use  without  delay  local  applications  of  stramonium,  belladonna,  or  chloro- 
form, and  hypodermic  injections  of  sulphate  or  muriate  of  morphia; 
when  the  pain  is  relieved  b}'^  these  means,  iron  becomes  of  use  by  curing 
the  general  condition  upon  which  the  disease  depends  ;  it  has  thus  a 
powerful  effect  in  preventing  relapses.  It  has  not  seemed  to  us  that  the 
carbonate  of  iron  has  any  special  utility,  but  that  all  the  preparations  of 
iron,  if  given  in  large  doses,  possess  the  same  properties. 

Gastralgias. — In  chlorotic  women,  or  women  who  present  some  of  the 
.symptoms  of  chlorosis,  gastralgia  has  certain  special  features  upon  which 
it  is  necessary  to  dwell.  At  the  outset  it  is  not  continuous,  but  re- 
turns at  intervals  of  two,  three,  or  four  days;  at  a  later  period  the  inter- 
vals diminish,  and  the  attacks  occur  daily,  or  several  times  in  the  twenty- 
four  hours;  their  return  is  most  apt  to  be  caused  by  eating  something. 
If  the  food  is  of  a  class  which  fatigues  the  patient,  the  pain  may  follow 
directly  upon  the  ingestion  ;  but  in  the  great  majority  of  cases  the  time 
elapsing  between  eating  and  the  occurrence  of  pain  is  at  least  two 
or  three  hours.  The  sensation  is  sometimes  that  of  a  weight  in  the  epi- 
gastric region,  sometimes  it  is  a  pain  resembling  violent  hunger,  sometimes 
cramps  or  heat  referred  to  the  same  region;  it  is  usually  confined  to  these 
])arts,  but  may  extend  to  the  neighboring  regions,  and  is  almost  always 
felt  behind  the  sternum  and  in  the  back  at  the  level  of  the  stomach.  It 
is  often  complicated  with  intercostal  neuralgia,  as  M.  Bassereau  has  re- 
marked, and  even  seems  to  be  an  extension  of  this  malady.     The  pains 


KECONSTITUENT    EEMEDIES.  11 

are  mostly  accompanied  by  a  sense  of  oppression,  revealed  by  deep  in- 
spirations, yawning-,  and  a  desire  to  undo  the  garments  which  press 
closely  upon  the  spot.  And  yet,  spite  of  this  frequent  and  often  pro- 
tracted suffering,  digestion  is  perfect,  food  is  retained,  nutrition  is 
elfected  suitably,  and  the  freces,  b}-  their  consistency  and  appearance,  in- 
dicate complete  digestion  of  food.  The  appetite  experiences  a  more  or 
less  distinct  alteration,  hunger  is  keen;  but  as  soon  as  any  food  is  swal- 
lowed an  invincible  satiety  is  felt.  Yet  some  eat  much  and  greedily ; 
but  the  meal  is  hardly  ended  when  they  are  hungry  again,  and  their  hun- 
ger sometimes  comes  so  suddenly  and  so  frequently  that  they  place  food 
by  their  bedside  to  consume  in  the  night.  Thirst  is  commonly  increased, 
though  there  is  neither  fever  nor  excessive  secretion;  it  shares  in  the  de- 
rangements which  all  the  sensations  connected  with  the  digestive  canal 
experience.  In  a  word,  sensation  is  disturbed,  and  function  may  be 
intact. 

By  these  marks  we  recognize  distinctly  a  nervous  affection,  and  we 
cannot  confound  these  symptoms  with  those  of  chronic  gastritis,  which  is 
commonly  accompanied  by  disgust  for  food,  sharp  pain  just  after  eating, 
difficulty  in  digestion,  and  is  soon  followed  by  diarrhoea  and  wasting. 
We  should  also  remark  that  the  pains  dependent  on  chronic  gastritis 
never  disappear,  to  be  replaced  by  neuralgia  of  the  face  or  head,  and 
conversely,  as  is  the  case  in  gastralgia.  This  point  is  of  great  import- 
ance, for  when  an  affection  thus  shifts  its  locality,  its  different  manifesta- 
tions probably  have  the  same  seat  and  nature,  as  may  be  seen  in  the  prog- 
ress of  a  catarrh  or  a  rheumatism. 

We  have  not  spoken  of  heart-burn  and  vomiting  as  diagnostic  points, 
for  experience  has  shown  us  that  these  symptoms  are  sometimes  found  in 
purely  nervous  gastric  affections,  and  we  think  they  may  be  neglected  as 
differential  signs. 

Gastralgia,  once  established,  is  accompanied  by  more  or  less  marked 
derangement  of  the  intestinal  functions;  the  stools  become  infrequent, 
the  faecal  matters  hard,  and  colics  are  common. 

Gastralgia  is  almost  always  accompanied  by  leucorrhoea.  This  dis- 
charge gives  no  indication  as  to  the  usefulness  of  iron,  for  it  is  observed 
equally  in  certain  gastralgias  in  which  iron  is  far  from  suitable. 

The  form  of  gastralgia  which  is  common  to  men  and  women  who  pre- 
sent no  symptom  of  chlorosis,  is  of  a  remarkably  fixed  character,  very  differ- 
ent from  that  Ave  have  just  described,  and  often  alternating  with  neural- 
gic pains  which  occupy  different  parts  of  the  body.  In  women  it  may 
coexist  with  a  high  complexion,  moderate,  but  bright  red  menstrual  dis- 
charges, and  chronic  leucorrhoea;  chlorotic  gastralgia  is  also  accompanied 
by  leucorrhoea,  but  the  menstrual  blood  is  light-colored,  and  the  complex- 
ion usually  pale.  Chlorotic  gastralgia  is  quite  readily  curable  by  iron,  but 
the  other  kind  is  almost  always  aggravated  by  the  same  remedy. 

Iron,  under  whatever  form  it  may  be  given,  is  useful  in  chlorotic  gas- 
tralgia; steel-filings,  a'thiops  mineral,  subcarbonate  of   iron,  hydrate  of 


1 2  THERAPEUTICS. 

peroxide  of  iron,  are  the  forms  most  commonly  used.  At  the  "outset,  we 
should  always  avoid  the  soluble  preparations,  because  they  often  increase 
the  pain.  Iron  is  to  be  combined  at  first  with  a  bitter  extract  and  some 
aromatic. 

It  sometimes  happens  that  a  minimum  dose  of  iron  increases  the  gas- 
tralgia  for  several  days.  This  will  discourage  the  patient,  but  not  the 
physician.  Let  him  continue  with  the  same  doses  until  the  gastralgia  is 
at  the  same  point  as  before  the  treatment  was  begun;  he  mav  add  to  the 
iron  some  centigrammes  of  belladonna  powder.  The  dose  of  iron  is  then 
to  be  increased,  and  so  on  until  at  each  meal  2  grammes  (30  gr.),  or  at 
least  1^  grammes  (23  gr.)  of  filings  are  taken.  Then  the  soluble  prepara- 
tions may  be  used,  and  continued  till  the  close  of  the  treatment.  We 
ought  to  enjoin  the  same  precautions  as  are  suitable  in  the  treatment  of 
chlorosis,  namely:  that  the  iron  should  be  suspended  and  resumed  several 
times,  and  even  when  gastralgia  is  quite  cured. 

When  pyrosis  coexists  with  gastralgia,  iron  is  usually  ill  borne.  We 
must  then  begin  by  giving  magnesia  in  a  slightly'  laxative  dose  for  several 
days,  and  after  a  little  while  an  infusion  of  quassia  or  simaruba.  After 
this  preparative  treatment,  iron  will  find  its  opportunity. 

What  we  have  said  of  neuralgia  of  the  face  is  also  applicable  to  gas- 
tralgia. It  sometimes  happens — especially  in  women  who  have  had  pains 
in  the  stomach  for  years — that,  in  spite  of  the  use  of  iron,  and  long  after 
the  appetite  and  strength  have  returned,  the  gastralgia  persists  with  dis- 
couraging frequency.  In  such  cases  the  cure  is  completed  by  plasters  of 
theriac,  frictions  with  cerate  of  stramonium  or  belladonna,  ammoniacal 
blisters,  either  simple  or  dressed  with  morphine,  cauteries,  moxas,  the  in- 
ternal use  of  bismuth,  magnesia,  the  poisonous  solanacea?,  opium.  The 
same  list  of  remedies  may  be  useful  in  certain  cases  in  combating  an  in- 
crease of  pain,  caused  by  the  use  of  ii'on  at  the  commencement  of  treat- 
ment. 

It  remains  to  point  out  certain  precepts  in  regard  to  regimen. 

The  food  which  the  stomach  digests  without  pain  varies  with  almost 
every  patient;  some  can  endure  nothing  but  milk;  some  are  less  tried  by 
meat  than  by  vegetables;  others  desire  meat-pies  and  similar  dishes. 

These  idiosyncrasies  must  be  taken  into  account  in  regulating  the 
diet,  for  we  must  not  imitate  those  physicians  who,  considering  the  diges- 
tibility of  foods  as  an  absolute  property,  impose  the  same  diet  on  all  their 
patients;  we  must  have  regard  to  the  susceptibilities  of  individuals,  and, 
however  bizarre  they  may  seem,  follow  the  lead  which  they  offer.  This  is 
the  method  which  we  have  followed  as  constantly  as  possible,  allowing  to 
the  patient  such  articles  of  food  as  her  daily  experience  has  shown  to  be 
the  most  digestible.  We  have  also  striven  to  limit  the  quantity  to  one- 
quarter  or  one-half  of  that  which  a  person  in  health  would  take;  and 
when  there  is  no  dislike  to  any  article,  we  order  rich  broths,  white  meats, 
roast  meat,  etc.,  avoiding  as  much  as  possible  the  farinaceous  vegetables, 
such  as  haricots  or  lentils,  the  too  frequent  use  of  which  in  hospitals  is 


RECONSTITUENT   REMEDIES.  13 

certainly  one  of  the  causes  which  render  success  less  frequent  in  them 
than  in  private  practice,  in  which  green  vegetables  and  fruits  are  pre- 
scribed. 

Neuralgias  occupying  other  parts  than  the  nerves  of  the  face  and 
stomach  must  be  treated  exactly  like  temporo-facial  neuralgia  as  regards 
local  means;  and  as  regards  the  chlorosis,  by  general  means. 

Asthma. — Amaurosis. —  W/ioojnng-cough. — There  are  certain  neuroses 
which  have  been  advantageously  treated  by  iron,  among  which  are  the 
above. 

Nervous  asthma  has  been  cured  by  M.  Battaille  of  Versailles  by  mar- 
tial preparations  continued  for  a  long  time  in  large  doses.  He  has  treated 
three  cases  thus:  all  were  women;  the  first  was  evidently  chlorotic,  while 
the  other  two  did  not  seem  to  be.  But  even  if  the  asthma  were  an  acci- 
dent of  chlorosis,  the  therapeutic  success  of  M.  Battaille  is  still  of  great 
importance,  as  serving  to  confirm  the  fact  which  we  have  so  often  men- 
tioned, to  wit,  that  therapeutic  indications  are  more  frequently  drawn 
from  the  general  condition  of  the  patient  than  from  local  symptoms. 

M.  Blaud  of  Beaucaire  has  reported  in  the  Bulletin  de  therapetttique 
(t.  XVII.  Nov.,  1839)  the  case  of  a  chlorotic  woman  who  had  suffered 
from  amaurosis  for  a  year.  The  physician  believed  that  the  blood,  in  its 
existing  state  of  impoverishment,  did  not  supply  a  proper  stimulus  to  the 
organ  of  sight.  He  gave  iron,  and  the  patient  recovered  her  sight  and 
her  health  at  the  same  time.  M.  Bretonneau  made  the  same  observation 
in  the  case  of  a  man  who  had  become  cachectic  as  a  result  of  prolonged 
intermittent  fevers. 

In  whooping-cough,  Drs,  Steymann  and  Chisholme  have  praised  the 
subcarbonate  of  iron.  This  remedy  is  not  employed  alone  at  all  stages. 
The  authors  strictly  prohibit  it  during  the  first  period,  and  order  that 
emetics  shall  always  be  given  previously.  Several  well-proved  facts  seem 
to  bear  testimony  in  favor  of  this  treatment.  The  dose  of  subcarbonate 
is  from  50  centigrammes  to  4  grammes  (8 — 60  grains).  In  a  few  davs, 
according  to  these  physicians,  the  violence  of  the  attacks  ceases,  and  soon 
nothing  remains  but  a  catarrhal  cough.  We  regret  that  we  liave  not 
tried  this  plan  in  our  own  practice. 

Menorrliarjia. —  Amenorrhcea.  — Ilcemorrhage.  — Ancemia.  —  Many 
physicians,  good  observers,  too,  think  that  chlorosis  is  necessarily  char- 
acterized by  a  marked  diminution  or  a  total  suppression  of  the  monthly 
flow.  They  regard  the  menorrhagia,  that  is,  the  excessive  flow,  as  so 
rare  an  occurrence  that  they  formally  exclude  it.  But  they  cannot  have 
failed  to  see  often,  in  their  own  practice,  women  who  are  deeply  anaemic 
and  suffer  from  all  the  general  symptoms  of  chlorosis,  who  sifffer  abun- 
dant losses  of  blood  every  month.  In  this  case  they  make  a  distinction; 
they  call  the  latter  class  anaemic,  and  those  whose  menses  are  deficient, 
chlorotic. 

And  yet,  as  we  just  said,  these  anasmic  women  have  all  the  symptoms 
of   chlorosis — the   extreme   pallor,  the  deficient  color  of  the  blood,  the 


1 4  THERARE  UTICS. 

bellows  murmur  in  the  heart  and  the  chief  vessels,  and  the  various  neu- 
ralgias; so  that,  if  we  should  examine  all  their  functions  except  those  of 
the  generative  organs,  we  could  not  fail  to  see  chlorosis. 

We  shall  try,  in  our  turn,  to  make  a  distinction  between  anaemia 
and  chlorosis.  Anaemia  is  an  accidental  condition,  caused  directly  and 
without  an  intermediate  stage  by  a  great  loss  of  blood;  a  person  becomes 
anaemic  in  a  few  days  or  hours.  Chlorosis  is  a  permanent  malady,  usu- 
ally slow  in  developing,  and  slow  to  leave  the  patient;  always  ready  to 
he  produced  by  apparently  the  most  indifferent  cause.  Anjismia  is  essen- 
tially a  transitory  state;  a  few  weeks  are  enough  to  restore  the  blood  and 
the  strength  completely,  without  any  other  remedies  but  a  good  diet. 
Relapse  is  never  to  be  feared  unless  a  new  loss  of  blood  occurs. 

M.  liurcq  has  added  certain  other  points  of  distinction.  He  says  that  he 
has  observed  that  cutaneous  sensibility  is  normal  in  anaemic  patients,  and 
changed  in  the  chlorotic;  the  antesthesia  differs  in  the  different  regions 
of  the  skin.  He  adds  that  muscular  force  in  the  anaemic  is  nearly  equally 
diminislxHl  in  all  the  muscles,  while  in  the  chlorotic  the  loss  of  force 
differs  in  the  different  groups  of  muscles;  in  an  anannic  person,  the  rela- 
tive power  of  the  right  and  left  arm,  for  instance,  is  as  in  health,  while  in 
the  clilorotic,  the  right  side  may  be  more  weakened  than  the  left,  or  in- 
versely if  the  person  be  left-handed  {Gazette  cles  hopitaux,  1864,  p.  118). 

Up  to  this  point  the  distinction  is  as  clear  as  possible;  but  in  practice, 
nature  by  no  means  divides  the  sick  into  two  such  separate  camps. 

We  may  see  every  day  the  action  of  moral  causes  in  producing  chlo- 
rosis in  a  woman  or  girl;  still  oftener,  the  malady  dates  from  the  first 
application  of  leeches,  which  evacuated  but  a  small  quantity  of  blood. 

If  we  understand  this,  we  can  easily  see  how  an  abundant  bleeding 
at  the  nose,  venesection,  or  repeated  leechings,  or  a  large  menstrual  dis- 
charge, may  bring  a  patient  into  such  a  condition  that  chlorosis  appears. 
Instead  of  simple  anjiemia,  transitory,  and  curable  by  nature  unaided,  there 
is  a  special  state  of  the  economy  in  which  the  blood  becomes  more  pale 
and  fluid  every  day,  although  the  original  losses  of  blood  have  not  been 
repeated. 

Here,  then,  anaemia  has  become  the  starting-point  of  chlorosis;  it  has 
predisposed  the  economy  to  chlorosis,  has  rendered  the  latter  easy,  and 
its  development  rapid. 

It  is  now  proper  to  see  what  part  antemia  and  chlorosis  may  play  in 
hitmorrhages. 

We  need  not  attend  to  the  classic  distinction  between  active  and  pas- 
sive hiemorrhage;  but  we  must  admit  that  haemorrhages  from  the  uterus, 
and  othei*s,  are  sometimes  associated  with  a  condition  of  energetic  reac- 
tion and  a  superabundance  of  life,  and  at  other  times  occur  in  persons 
in  exactly  the  opposite  state.  We  will  admit  tliat  in  all  liiemorrhages 
(traumatic  and  hypostatic  excepted)  there  is  a  previous  local  action,  analo- 
gous or  identical  with  the  first  phenomena  of  inflammation;  but  we  must 
exclude  from  present  consideration  all  except  general  organic  conditions. 


RECONSTITUENT    REMEDIES.  15 

The  general  state  of  the  system  plays  here  an  extremely  important 
part.  When  the  menstrual  molimen  is  the  same,  but  the  condition  of 
the  blood  is  different,  it  is  impossible  that  the  flow  should  not  be  consid- 
erably modified  by  the  degree  of  plasticity  of  the  blood;  and,  in  fact,  it 
is  modified. 

To  take  the  simplest  case  first:  see  what  happens  in  a  recent  wound 
in  a  vigorous,  plethoric  man,  and  in  one  who  is  profoundly  anaimic. 

In  the  former,  the  haemorrhage  is  slight  and  quickly  stops;  though 
large  arterial  trunks  hav'e  to  be  tied,  it  is  needless  to  use  a  haemostatic  to 
arrest  capillary  bleeding;  but  in  the  other,  even  after  the  smallest  trunks 
have  been  tied,  a  considerable  amount  of  blood  or  of  reddish  serum  con- 
tinues to  flow,  which  stains  the  dressing  deeply,  and  by  its  abundance 
may  involve  danger  to  life. 

What  is  observed  in  men  may  be  seen  in  the  different  species  of  ani- 
mals. A  dog's  legs  may  be  cut  off,  he  may  suffer  enormous  mutilations, 
without  danger  to  life  from  htemorrhage,  while  rabbits  die  from  bleeding 
after  a  slight  wound.  The  plasticity  of  the  blood  of  dogs  forms  an  obsta- 
cle to  haemorrhage,  while  the  liquidity  of  the  blood  in  rabbits  favors  it. 

The  tendency  of  ancemic  persons  to  haemorrhage  is  marked,  from  the 
moment  the  loss  of  blood  has  occurred.  If  leeches  are  applied  to  a  child 
for  the  first  time,  the  loss  of  blood  will  be  much  less,  other  things  being 
equal,  than  that  which  will  follow  the  second  application;  and  this,  still 
less  than  at  the  third;  until  (as  we  have,  unfortunately,  often  seen)  the 
bite  of  one  leech  may  cause  a  fatal  haemorrhage  in  a  child  previously  ex- 
hausted by  bleeding. 

But  if  antemia,  considered  as  a  transitory  and  as  it  were  acute  condi- 
tion, may  have  such  an  immense  influence  on  hiemorrhage,  how  much 
greater  will  be  this  influence  if  it  has  lasted  for  a  long  time,  especially  if 
chlorosis  with  all  its  accompaniments  has  been  developed  ! 

Now  let  us  transfer  to  the  mucous  membrane  of  the  uterus  that  which 
we  just  said  in  general.  If  a  woman  or  a  girl  has  an  excessive  menstrual 
discharge,  the  interval  between  the  periods  will  doubtless  suffice  for  some 
months  to  restore  the  blood;  but  the  repetition  of  the  same  accident  will 
soon  bring  on  antemia,  and  at  last  chlorosis.  If  the  molimen  remains  the 
same,  the  flow,  as  we  showed  above,  will  become  more  abundant,  and  chlo- 
rosis, a  cause  of  the  increase  of  haemorrhage,  will  itself  be  aggravated  by 
the  hiBmorrhage;  and  the  patient,  revolving  in  this  circle,  will  soon  be  in 
danger. 

Let  us  therefore  not  lose  from  sight  these  leading  facts:  chlorosis  is 
produced  by  excessive  menstrual  discharges;  chlorosis  may  render  the 
discharge  still  more  profuse.     In  other  words — 

Too  copious  menses  cause  thinness  and  dissolution  of  the  blood; 

Thinness  and  dissolution  of  the  blood  are  a  cause  of  uterine  haemor- 
rhage. 

There  is,  then,  a  form  of  chlorosis  which  might  be  called  inenorrliagic. 

Is  this  form  common  in  young  gii'ls  ?     It  is  rare;  we  estimate  from  our 


1 6  THE  K  APE  UTICS. 

records  that  it  forms  the  twelfth  part  of  the  cases.  In  adult  women  it  is 
more  common.  Yet  we  would  say  that  our  observations  in  private  and 
hospital  practice  do  not  include  a  sufficiently  large  number  of  facts  to  fur- 
nish complete  statistics. 

We  have  collected  a  considerable  number  of  cases  of  menorrhagic  chlo- 
rosis, both  in  young  girls  and  in  married  women.  Not  one  of  these  pa- 
tients had  uterine  lesions;  this  fact  we  proved  by  examination  of  all  the 
married  women;  but  in  the  case  of  the  girls,  where  such  examinations 
would  have  been  difficult  and  unsuitable,  we  judged  from  the  rapidity  of 
recovery,  and  the  good  health  which  we  observed  for  several  years  after- 
wards, that  the  uterus  was  exempt  from  severe  lesions. 

In  speaking  of  treatment,  two  principal  points  are  obvious:  one,  men- 
orrhagia;  the  other,  chlorosis. 

Menorrhagia  is  combated  by  remedies  which  we  usually  think  contra- 
indicated  in  chlorosis;  the  treatment  of  chlorosis  is  supposed  to  be  apt  to 
excite  the  menstrual  flow.  It  would  seem  impossible  to  avoid,  striking 
upon  one  of  these  two  rocks. 

Let  us  consider  whether  the  preparations  of  iron  are  really  emmena- 
gogues.  It  cannot  be  doubted  that  iron  restores  the  health  and  the  ute- 
rine flow  in  achlorotic  woman  who  has  amenorrhoea;  but  does  the  iron  act 
as  an  emmenagogue  or  as  a  reconstituent '? 

Whenever  we  give  ferruginous  drugs  in  cases  of  chlorosis  complicated 
with  amenorrhoea,  the  first  phenomenon  observed  is  a  return  of  color  to 
the  tissues,  and  at  the  same  time,  diminution  of  the  depraved  appetite, 
the  pains  in  the  stomach,  the  palpitations  of  the  heart,  shortness  of  breath, 
bellows  murmur  in  the  blood-vessels,  thirst,  etc.,  so  that,  after  six  or 
eight  weeks  of  a  properly  conducted  treatment,  the  appearance  of  most 
vigorous  health  returns;  all  goes  well,  but  the  courses  do  not  yet  ap- 
pear. If  we  continue  the  treatment  it  is  not  rare  to  see  actual  sanguine 
plethora  supervene  while  the  menses  are  still  absent. 

Health  is  then  re-established,  chlorosis  is  cured — but  amenorrhcea 
persists.  Soon,  in  their  turn,  the  menses  appear  and  take  the  normal 
course.  In  such  a  case,  iron  acts  at  first  as  a  reconstituent;  and  after 
the  health  has  been  re-established,  the  functions  of  health,  including  men- 
struation, are  re-established  in  their  turn.  The  patient  does  not  recover 
health  because  her  menses  have  returned  under  the  influence  of  iron,  but, 
on  the  contrary,  the  menses  return  because  health  has  been  recovered 
under  the  influence  of  iron.  The  point  is  completely  proved,  for  if  it 
were  otherwise,  we  should  have  seen  the  return  of  menstruation  give  the 
signal  for  the  return  of  health;   whereas  the  contrary  has  occurred 

It  is  because  they  have  not  followed  the  evolution  and  succession  of 
these  different  phenomena  that  practitioners  have  always  imagined  iron 
to  be  an  emmenagogue;  and  this  error,  accredited  for  ages,  will  long 
continue  to  prevail  against  the  most  manifest  facts,  against  the  closest 
observation,  for  we  are  so  made  as  to  like  to  hold  to  an  error,  and  to  resist 
truth  obstinately. 


KECOlSrSTITrrENT    EEMEDIES.  17 

To  go  further,  not  only  is  iron  not  an  emmenagogue,  but,  on  the  con- 
trary, it  is  a  haemostatic.  Thus,  the  experiments  we  have  made  on  a 
large  scale  in  our  hospital  show  that,  in  women  whose  menses  are  regular, 
and  who  are  free  from  chlorosis,  the  use  of  iron  most  frequently  retards 
the  menstrual  flow  and  diminishes  it.  We  say  most  frequently,  and  not 
always.  • 

Next,  let  us  see  how  the  indications  in  menorrhagic  chlorosis  are  sim- 
plified : 

Leading  indication,  to  treat  the  chlorosis. 

Secondary  indication,  to  treat  the  menorrhagia. 

And  the  latter  is  so  truly  secondary  that  we  scarcely  ever  have  time 
to  attend  to  it. 

In  fact,  by  giving  iron  in  large  doses  between  two  menstrual  periods, 
we  easily  restore  the  plasticity  of  the  blood;  before  twenty-five  days 
are  past  the  complexion  has  regained  almost  its  normal  color,  the  subcu- 
taneous veins  have  recovered  their  volume  and  their  bluish  tint.  When, 
therefore,  the  menses  reappear,  the  blood  is  already  in  such  a  condition 
that  hemorrhage  is  less  easy,  and  the  discharge  is  often  much  less  abun- 
dant, though  much  more  highly  colored. 

We  have  sometimes,  nevertheless,  seen  menorrhagia  increased  in 
spite  of  the  treatment,  and  perhaps  as  a  consequence  of  the  treatment; 
but  even  in  this  case  the  debility  and  pallor  which  used  to  follow  the 
menstrual  period  were  much  less  marked  than  in  the  preceding  month, 
and  a  few  days  made  up  for  the  loss.  But  observe  that  in  such  a  case, 
even  when  the  loss  of  blood  is  absolutely  greater  than  before,  the  relative 
loss  is  much  less.  It  follows  that  the  health  suffers  nothing,  or  next  to 
nothing,  from  the  bleeding,  since  the  injury  is  repaired  almost  at  once  by 
the  treatment. 

But  if,  in  spite  of  the  use  of  iron,  menstruation  is  as  abundant  as  pre- 
viously, if  its  amount  is  even  increased,  there  are  other  remedies  which 
almost  always  suffice,  in  the  front  rank  of  which  we  would  place  powdered 
ergot,  digitalis,  acids,  rhatany,  plugging,  powdered  bark  of  yellow  cin- 
choi,ia  given  in  doses  of  two  or  three  grammes  a  day  (30 — 45  gr. ), 
etc.,  etc. 

As  soon  as  the  menses  are  over,  we  must  resume  the  use  of  iron  for 
eight  or  ten  days,  in  a  dose  proportioned  to  the  patient's  weakness.  If  a 
little  anj^mia  or  chlorosis  remains,  we  should  insist  on  iron  during  the 
entire  month,  and  even  during  the  menstrual  period,  unless  the  menses 
are  so  abundant  as  to  require  the  use  of  another  remedy. 

Such,  in  rapid  outline,  are  the  practical  rules,  to  which  the  physician 
may  add  those  details  which  are  best  taught  by  having  to  treat  an  obsti- 
nate malady. 

Nose-bleed,  in  chlorotic  patients,  observes  the  same  laws  as  uterine 
hemorrhage.  We  have  known  a  young  lady  of  twenty-one  who  had  ex- 
tremely abundant  nose-bleed  every  day.  Acids,  astringents  taken  in- 
ternally and  by  injection  into  the  nasal  cavities,  had  been  tried  in  vain  ; 
2 


18  THERAPEUTICS. 

powdered  cinchona,  taken  internally,  which  almost  always  succeeds  in 
these  cases,  had  likewise  failed;  the  bleeding  returned  continually.  The 
use  of  large  doses  of  subcarbonate  of  iron  cured  the  chlorosis  and  greatly 
checked  the  loss  of  blood. 

It  would  be  a  mistake  to  suppose  that  uterine  and  nasal  hjBmorrhao-e 
is  cured  by  iron  only  in  the  case  of  chlorotic  young  girls.  We  have 
treated  several  cases  in  women  at  the  turn  of  life,  who  were  exliausted 
by  repeated  metrorrhagia.  In  spite  of  the  apprehensions  of  the  physi- 
cians who  met  us  we  insisted  on  preparations  of  iron,  and  succeeded  in 
easily  checking  the  haemorrhage.  This  practice  is  conformable  to  that  of 
Phil.  Frid.  Gmelin  ("Dissert,  de  probato  tutoque  usu  interno  vitrioli 
ferri  adversus  hgemorrhagias  spontaneas  largiores "  (Tiibing.,  "  Thesaur. 
mat.  med.,"  t.  II.). 

Iron  in  this  case  has  a  double  action,  as  we  said  above.  At  first  it  re- 
pairs the  losses  of  cruor  and  fibrin;  next,  it  increases  the  plasticity  of 
the  blood,  makes  it  more  coagulable,  and  thereby  lessens  its  facility  of 
escape. 

Very  unlike  the  other  haemostatics,  which  for  a  moment  increase  the 
coagulability  of  the  blood  without  restoring  its  constitution  and  relieve 
only  the  actual  symptom,  iron  may  be  of  use  in  certain  phases  of  melaina 
and  hcemorrhoids;  not  as  combating  the  organic  lesion  which  gives  rise 
to  ha3morrhage,  but  as  remedying  the  consecutive  anaemia;  by  restoring 
the  plasticity  of  the  blood,  it  may  cure,  if  the  htemorrhage  depends  solely 
on  the  licfuefaction  of  the  blood,  and  may  limit,  if  the  liquefaction,  though 
consecutive,  is  itself  a  cause  of  liJEmorrhage.  In  a  word,  we  must  repeat 
here  that  which  we  said  before  under  metrorrhagia.  Let  us  recall  the 
results  of  the  analyses  made  by  MM.  Andral  and  Gavarret.  They  found 
that,  in  cases  of  sanguineous  apoplexy  with  effusion,  the  globular  portion 
was  more  abundant  than  in  most  patients.  In  these  haemorrhages,  justly 
called  active,  iron  would  very  probably  be  injurious.  But  if  these  observ- 
ers had  analyzed  the  blood  of  persons  exhausted  by  hemorrhoidal  flux, 
they  would  have  clearl}^  found  a  diminution  of  the  globules,  which  would 
have  proved  the  propriety  of  using  iron. 

We  may  then  conclude:  1st,  that  iron  is  not  an  emmenagogue;  2d, 
that  in  chlorotic  patients  it  seems  to  provoke  the  menstrual  discharge, 
because  it  cures  the  chlorosis;  3d,  that  in  women  in  health  it  usually 
modifies  the  uterine  flux;  4th,  that  it  restrains  uterine  haemorrhage,  at 
least,  when  apparently  disconnected  with  plethora;  5th,  that  it  moder- 
ates the  various  haemorrhages  which  occur  in  chlorosis. 

Dysmenorrhoea. — When  the  menses  are  painful,  and  the  blood  a  little 
discolored,  the  use  of  iron  in  the  interval  very  often  suflices  to  put  an  end 
to  the  symptoms;  but  when  this  treatment  is  inadequate  we  should  add 
vaginal  injections  of  a  strong  decoction  of  stramonium  or  belladonna,  or 
of  a  little  oil,  in  which  a  few  drops  of  chloroform  are  dissolved. 

Sterility. — The  preparations  of  iron  make  women  fertile;  this  fact  is 
as  authentic  as  its  emmenagogue  properties,  and  was  clearly  stated  by 


EECONSTITUENT   REMEDIES.  19 

Hippocrates  (Opera,  ed.  Foesii,  t.  I.,  sect,  v.,  p.  686).  The  fact  is  easily- 
explained.  Chlorotic  women  are  usually  sterile,  and  so  are  those  whose 
menses  are  excessive  or  very  painful;  iron,  therefore,  which  relieves  all 
these  troubles,  is  readily  seen  to  be  capable  of  relieving  the  sterility 
which  is  due  to  them.  M.  Blaud,  of  Beaucaire  (^Bulletin  de  therapeuti- 
qiie,  t.  XVII.,  no\^,  1839),  has  added  facts  which  confirm  this  view. 

Cachexiai. — To  say  (as  did  the  writers  of  former  centuries)  that  iron 
cures  the  cachexiie,  is  to  use  a  very  vague  expression;  yet  the  expression 
is  true  in  some  points. 

If  the  serous  portions  of  the  blood  predominate,  in  consequence  of 
cancer  or  scrofula;  if  hsemorrhage  from  a  cancerous  ulceration  causes 
anaemia;  if  poor  and  insufficient  food  impoverishes  the  blood,  there  is  no 
doubt  that  by  the  use  of  iron  we  may  get,  not  a  cure,  but  a  beneficial 
modification  of  the  general  health;  but  the  hope  of  cure  which  may  arise 
is  always  destined  to  disappointment,  since  the  cause  remains,  and  is 
more  mighty  to  destroy  than  the  remedy  to  build  up. 

Dropsies. —  Visceral  engorrjements. — It  is  certain  that  in  a  very  ad- 
vanced stage  the  heart  no  longer  fulfils  its  functions  normally,  and  that, 
besides,  the  blood  has  not  its  natural  qualities.  The  consequent  disturb- 
ances of  circulation,  both  general  and  capillary,  affect  the  economy  in  the 
same  way  as  if  there  were  an  organic  lesion  of  the  heart.  Hence,  en- 
gorgement of  the  lungs,  hypertrophy  of  the  liver,  dropsy,  anasarca.  Iron, 
by  curing  chlorosis,  cures  all  these  symptoms;  but  we  must  not  infer  that 
iron  can  cure  them  when  due  to  other  causes. 

Intermittent  fevers. — In  the  same  way  we  may  speak  of  the  influence 
of  iron,  not  on  the  fever,  but  on  the  accidents  which  may  retard  a  cure 
or  provoke  a  relapse.  Bretonneau  has  shown  that  the  miasms  which 
cause  these  fevers,  before  they  developed  into  well-marked  paroxysms, 
often  produced  anjemia;  that  intermittent  fever  developed  with  a  readi- 
ness proportioned  to  the  amount  of  blood  which  the  patient  had  lost,  or 
the  degree  to  which  the  blood  was  impoverished;  that  the  fever,  after 
lasting  some  time,  brought  about — especially  in  women — a  very  pro- 
nounced state  of  anaemia,  so  that  antemia  was  at  once  a  predisposing 
cause  and  an  effect. 

Sydenham  and  Stoll  knew  from  experience  that  chalybeate  wine,  and, 
in  general,  the  preparations  of  iron,  are  a  useful  adjunct  to  cinchona. 
Bretonneau,  in  imitation  of  these  great  masters,  introduced  it  into  his 
hospital  practice,  and  found  it  extremely  useful  in  preventing  the  access 
and  return  of  intermittents,  and  in  curing  the  leuco-phlegmasia  and  the 
splenic  engorgement  which  follow  prolonged  fevers.  He  was  accustomed 
to  give  iron  in  these  cases  several  months  at  a  time,  with  preparations  of 
cinchona.  The  direct  febrifuge  action  attributed  by  Marc  to  iron  {Journ. 
gen.  de  tried.,  1810),  by  Martin  {Bulletin  de  la  Societe  m'ed.  d'' emulation^ 
aotit,  1811),  and  by  d'Autier,  in  a  good  many  experiments  made  by  Bre- 
tonneau and  M.  Barbier,  of  Amiens,  has  not  been  proved. 

As  regards  the  use  of  Prussian  blue  as  a  substitute  for  cinchona  in 


20  THERAPEUTICS. 

treating  intermittents,  we  will  speak  further  of  it  under  the  head  of  pre- 
parations of  cyanogen.  We  will  state,  however,  that  we  have  very  little 
faith  in  its  efficacy  in  the  class  of  cases  which  we  are  considering. 

Scrofula. — Among  the  many  remedies  used  in  this  disease,  iron  occu- 
pied the  first  rank  before  the  discovery  of  iodine.  But  its  action  is  very 
equivocal,  and  the  known  efficacy  of  iodide  of  iron  in  these  diseases  is  not 
a  sufficient  proof. 

Certain  experiments  have  been  made  by  CI.  Bernard  upon  animals, 
and  have  been  repeated  by  M.  Quevenne  upon  himself  with  much  care, 
which  show  that  iodide  of  iron,  when  introduced  into  the  stomach,  almost 
immediately  undergoes  a  sort  of  resolution  into  its  constituent  elements. 
In  a  very  short  time,  iodine,  having  been  rapidly  absorbed,  is  found  in 
the  saliva,  and  passes  in  considerable  quantity  into  the  urine.  This  eli- 
mination continues,  at  first  in  increasing  amounts,  then  decreasing,  so 
that  after  forty-eight  hours  three-fourths  of  the  iodine  ingested  has  been 
rejected  by  the  emunctories,  while  after  the  same  time  the  quantity  of 
iron  absorbed  and  carried  away  by  the  metalloid  is  hardly  appreciable. 
From  this  extreme  difference  in  the  results  of  absorption  may  we  not  be 
justified  in  inferring  that  in  the  very  special  affections  for  which  iodide 
of  iron  is  habitually  used  (that  is,  in  scrofula),  the  greater  part  of  the 
action  is  due  to  iodine,  without  claiming  that  that  of  iron  is  absolutely 
null? 

Diabetes. — Heine,  of  Berlin,  regards  the  sulphate  of  iron,  taken  inter- 
nally, as  a  kind  of  specific  for  the  diabetes  mellitus  of  children.  He  quotes 
from  the  Journal  des  maladies  des  enfants  two  cases  which  seem  quite 
convincing;  but  before  pronouncing  upon  the  efficacy  of  this  remedy,  we 
shall  see  whether  our  personal  experience  confirms  such  rapid  results  in  a 
disease  usually  so  obstinate. 

Leucorrhoea. — jBlennorrhagla. — In  simple  utero-vaginal  catarrh  con- 
nected with  chlorosis,  iron  has  a  manifest  utility;  but  it  increases  the  white 
discharges  in  women  of  high  complexions.  It  has  very  little  influence 
upon  the  leucorrhoea  which  accompanies  ulceration  of  the  neck  of  the 
womb. 

Blennorrhagia  has  been  cured  by  iron  in  some  cases;  in  the  last  stage 
of  the  disease,  after  the  symptoms  of  inflammation  are  gone,  workmen 
often  cure  themselves  by  drinking  for  several  days  large  quantities  of  the 
water  in  which  the  forge-men  quench  red-hot  iron,  which  contains  a  good 
deal  of  iron.  It  would  doubtless  be  better  to  use  large  doses  of  ferrugi- 
nous preparations,  or  of  the  tartrate  or  chloride  of  iron.  We  will  add  that 
M.  Ricord  very  often  uses  a  solution  of  tartrate  of  iron  and  potassium  (4 — 8 
grammes  to  100  grammes  of  water)  to  dress  venereal  ulcers,  especially 
when  these  ulcers  threaten  to  assume  a  phagedii^nic  character. 

Preservation  of  water. — For  some  time,  sheet-iron  boxes  have  been 
used  to  hold  the  water  for  long  voyages.  The  subcarbonate  of  iron, 
which  forms  and  dissolves  in  minute  quantities  in  the  water,  has  the 
double  advantage  of  preventing  the  development  of  plants  and  infusorial 


KECONSTITUENT    EEMEDIES.  21 

animalcules,  and  consequently  preserving  it  from  corruption,  while  it  also 
acts  favorably  on  the  health  of  the  sailors. 

Poisoning  by  arsenic. — The  hydrated  sesquioxide  of  iron  has  been 
recommended  in  the  treatment  of  poisoning  by  arsenious  acid. 

In  this  case  an  insoluble  arsenite  of  iron  is  formed;  or  at  least,  a  salt 
so  far  insoluble  that  purgatives  can  remove  it  before  it  has  time  to  affect 
the  system.  But  the  arsenite  of  iron  is  easily  dissolved  by  the  hydro- 
chloric and  lactic  acids  which  are  naturally  formed  in  the  stomach;  it  is 
therefore  important  to  neutralize  them,  which  may  be  done  by  giving  the 
sesquioxide  in  excess. 

This  important  remedy  can  only  be  of  use  when  the  physician  is  very 
quickly  called,  for  a  few  moments  are  enough  for  arsenic  to  inflict  gen- 
eral and  local  injuries  which  are  irremediable. 

In  certain  medico-legal  cases  it  may  become  of  extreme  importance  to 
know  that  the  hydrated  sesquioxide  of  iron  itself  is  often  arsenical,  when 
prepared  from  commercial  sulphate  of  iron. 

Poisoning  hy  salts  of  copper. — Iron-filings  are  among  the  best  anti- 
dotes in  cases  of  poisoning  by  salts  of  copper.  The  filings  should  have 
all  their  metallic  lustre.  The  reaction  is  as  follows  :  an  innocuous  salt 
of  iron  is  formed,  and  the  copper  is  precipitated  in  the  metallic  state. 


Use  of  Preparations  of  Iron  in  External  Maladies. 

The  soluble  preparations  usually  possess  more  or  less  astringent  power. 
They  drive  the  blood  from  the  tissues  with  which  they  come  in  contact, 
they  suppress  or  modify  the  secretions,  they  arrest  or  check  haemorrhage, 
and  in  general,  all  kinds  of  flux;  in  a  word,  they  exactly  satisfy  the  vari- 
ous requirements  which  we  commonly  try  to  meet  by  the  substances  called 
astringents.  In  this  respect  it  is  important  to  establish  one  distinction. 
The  insoluble  preparations  are  preferable  for  internal  use,  and  the  solu- 
ble for  external  ;  but  the  latter  may  also  be  used  internally. 

Among  the  soluble  salts  most  in  use  for  external  application,  are  the 
sulphate,  the  muriate,  the  acetate  of  the  peroxide,  and  especially  the 
perchloride,  which  deserves  our  more  special  attention. 


Perchloride  of  Iron. 

External  Use. — For  some  years  this  agent  has  held  an  important  place 
in  therapeutics,  both  as  a  hfemospastic,  and  as  a  hasmostatic  and  astrin- 
gent. 

Every  one  knows  that  Pravaz  was  the  first  to  use  it  by  injection  in 
the  cure  of  aneurism. 

The  first  trials  were  far  from  encouraging;  but  it  seems  to  have  had 
better  luck  since:  some  half-successes  in  certain  aneurisms,  more  complete 


22  THERAPEUTICS. 

successes  in  the  treatment  of  varices  and  hasmorrhoids,  both  with  the 
perchloride  and  with  the  acetate  of  the  peroxide,  are  the  latest  results; 
so  that  the  method  seems  to  have  some  chance  of  redeeming  the  disgrace 
into  wliich  its  hrst  failures  cast  it. 

Further  careful  trials  are  needed  before  we  can  definitely  judge  of 
this  great  question. 

If  the  treatment  by  injection,  in  diseases  of  the  arteries  or  veins,  tri- 
umphs over  the  immense  obstacles  which  arrested  it  at  its  birth,  the  honor 
will  belong  first  to  Pravaz,  who  took  the  initial  step,  and  next  to  the  in- 
telligent perseverance  of  the  surgeons  of  Lyons. 

However  doubtful  may  be  the  value  of  perchloride  of  iron  as  injected 
into  the  blood-vessels,  there  is  no  doubt  as  regards  its  external  use. 

In  a  memoire  presented  to  the  Academie  des  sciences,  in  September 
1853,  M.  Putrequin  mentioned  a  large  number  of  cases  in  which  the  per- 
chloride of  iron,  or  of  iron  and  manganese,  may  be  used  with  advantage 
externally. 

Thus,  when  the  bleeding  comes  in  a  sheet,  from  a  wounded  surface, 
he  states  that  it  suffices  to  wash  the  surface  with  cold  water,  and  then 
to  apply  a  compress  soaked  in  a  mixture  of  a  teaspoonful  of  the  concen- 
trated solution  of  perchloride  in  a  glass  of  water.  If  the  flow  is  not  ar- 
rested, we  shall  succeed  l^y  adding  to  the  mixture  a  second  teaspoonful  of 
the  perchloride. 

If  the  wound  is  unequal  and  irregular,  a  tampon  of  charpie  moistened 
in  the  same  liquid  is  used  before  the  compress.  This  procedure  may  suf- 
fice even  when  the  bleeding  comes  from  a  small  artery.  The  charpie 
might  be  replaced  by  amadou,  sponge  or  linen,  which  will  further  serve 
as  a  compressor  of  the  vessel. 

A  plug  of  charpie  or  amadou  dipt  in  pure  perchloride  and  applied 
with  the  finger  instantly  checks  the  blood  from  leech-bites. 

This  measure  has  succeeded  in  cases  of  epistaxis  where  plugging  and 
other  haemostatics  have  failed. 

We  are  acquainted  with  no  better  means  of  arresting  dental  haemor- 
rhage, which,  as  we  know,  is  sometimes  so  refractory. 

The  solution  of  perchloride  has  been  proposed  in  sanguineous  tumors, 
haemorrhoids,  vascular  fungi;  and  by  Dr.  Yvonneau  {JBulletm  de  la  Soci- 
ete  d^ Indre-et- Loire,  1854)  in  the  treatment  of  ingrowing  nails. 

This  solution  has  been  of  good  service  in  various  affections  of  the 
genital  organs,  especially  in  metrorrhagia,  leucorrhcea,  and  laxity  of  the 
vaginal  walls. 

The  remedy  may  naturally  be  used  in  engorgements  of  the  neck  of 
the  uterus,  especially  those  varicose  or  inflamed  states  which  have  been  of 
late  commonly  treated  (perhaps  a  little  abusively)  by  caustics  and  heated 
iron:  for  where  alum  or  tannin,  applied  locally,  often  cures,  much  may  be 
expected  of  a  remedy  possessed  of  properties  so  remarkably  astringent, 
resolvent  and  haemostatic.  The  trials  which  have  lately  been  made  have 
entirely  justified  these  hopes.     Employed  alone,  or,  still  better,  associated 


RECONSTITUEKT    REMEDIES.  23 

with  collodion,  the  solution  has  effected  in  the  above-named  class  of  cases 
cures  which  promise  well  for  its  future  career. 

M.  Petrequin  says  that  the  perchloride  is  an  excellent  antiseptic  in 
gangrenous  wounds  and  fetid  suppurations.  Washing  with  a  solution  of 
various  strength  rapidly  removes  the  fetor — a  property  important  in  the 
hygiene  of  hospitals. 

For  some  years  past  a  large  number  of  physicians,  including  Drs. 
Bourot  and  Salleron,  have  studied  the  disinfectant  and  antiputrescent 
virtues  of  perchloride  of  iron;  it  may  be  said  that  the  excellent  results 
obtained  in  purulent  and  putrid  affections,  in  all  ill-conditioned  sores, 
and  especially  in  hospital  gangrene,  insure  to  this  remedy  an  important 
place  in  surgical  practice,  especially  military  surgery.  In  this  respect 
we  may  say  that  the  perchloride  may  rival  the  most  renowned  antiputres- 
cents,  such  as  the  iodated  preparations. 

The  perchloride  has  also  been  used  in  a  great  variety  of  obstinate 
scrofulous  affections  of  the  skin  and  mucous  membranes;  and  M.  Bazin, 
among  others,  has  found  it  very  useful  in  certain  malignant  scrofulidte. 
It  has  been  used  with  success  in  some  parasitic  diseases,  as  mentagra, 
tinea,  acne. 

Finally,  there  is  another  instance  of  external  use  which  deserves  special 
mention:  the  use  as  a  preservative  from  syphilis.  We  owe  this  new  ap- 
plication to  Dr.  Rodet,  a  distinguished  physician  of  Lyons.  Its  impor- 
tance may  be  immense,  if  the  future  confirms  the  results  which  are  an- 
nounced. 

Let  us  say,  first,  that  the  perchloride  of  iron,  whatever  its  deo-ree  of 
concentration,  does  not  of  itself  suffice  to  confer  this  immunitv;  but  that, 
in  order  to  insure  complete  efficiency,  a  free  acid,  such  as  muriatic — or 
better,  nitric — must  be  added  to  it. 

M.  Burin  de  Buisson,  who  has  carefully  studied  the  chemical  action 
of  the  perchloride,  explains  the  necessity  of  this  addition  as  follows: 
When  the  perchloride  is  applied  over  the  point  of  inoculation,  the  imme- 
diate effect  is  the  formation  of  a  coagulum  in  the  albuminous  portions  of 
the  blood,  which,  acting  as  a  plug,  prevents  the  preservative  liquid  from 
penetrating  deeply  enough  to  reach  and  completely  destroy  the  virus. 
Now,  the  addition  of  an  acid  removes  this  obstacle  by  redissolving  the 
coagulum,  and  by  aiding  the  penetration  of  the  perchloride  into  all  the 
folds  of  the  mucous  membranes  and  the  interior  of  the  tissues  to  which 
it  is  applied. 

According  to  the  same  chemist,  the  perchloride  acts  by  coagulating, 
and  not  at  all  by  cauterizing  ;  it  preserves,  by  forming  an  obstacle  to  the 
absorption  of  the  virus,  by  drawing  out  the  albuminous  fluids  which  sur- 
round the  inoculated  point,  and  causing  them  to  coagulate  as  they  ap- 
proach that  point.  In  this  way  the  virus,  seized  and  imprisoned  as  it 
were  in  the  midst  of  the  albuminous  coagula,  is  first  neutralized,  or  de- 
stroyed, and  soon  eliminated. 

Whether  the  preservative  liquid  invented  by  M.  Rodet  acts  as  a  co- 


24  THERAPEUTICS. 

agulant  or  as  a  caustic,  is  not  a  question  for  us  to  decide.     The  following 
formula  has  been  adopted  as  the  best,  after  long  trials: 

]^.  Pure  water 24  grammes  (370  grains). 

Perchloride  of  iron,  liquid,  at  30°. . .    12  grammes  (185  grains). 

Hydrochloric,  or  better,  citric  acid . .     4  grammes  (  61  grains). 
M.  ^ 

We  cannot  now  enter  into  the  details  of  the  great  number  of  experi- 
ments which  have  been  made  in  the  hospitals  of  Lyons;  but  we  should 
add,  that  the  results  are  nearly  constant,  and  seem  to  show  that  the  Ro- 
det  liquid  possesses  the  power  of  neutralizing  the  virus  of  syphilis  in- 
troduced by  inoculation,  and  of  preventing  the  development  of  consecutive 
accidents.  We  will  add  that  the  same  effects  have  been  observed  with 
vaccine  virus. 

But  will  these  preservative  powers  act  with  equal  certainty  when  the 
liquid  is  applied  after  the  sexual  act  ?  Certainly,  the  results  thus  far  are 
adapted  to  give  rise  to  hope;  but,  on  the  other  hand,  it  would  be  a  rash 
thing,  in  so  grave  a  matter,  to  utter  our  judgment  before  a  long  and  se- 
vere trial  had  been  made.  Besides,  in  this  case,  the  value  of  the  remedy 
is  not  the  only  point  in  question,  and  success  must  depend  on  many  con- 
siderations of  quite  another  nature. 

The  method  of  application,  as  given  by  the  inventor,  is  as  follows: 

As  quickly  as  possible,  after  the  suspected  coitus,  the  part  is  washed 
in  water,  to  which  is  added  the  preservative  liquid,  in  the  proportion  of 
one  tablespoonful  to  one  or  two  glasses  of  water.  Charpie,  or  linen, 
soaked  in  the  pure  liquid,  is  immediately  laid  on  the  part  supposed  to  be 
contaminated,  and  allowed  to  remain  for  a  quarter  of  an  hour,  care  being 
taken  that  the  liquid  penetrates  all  the  folds  of  skin  and  mucous  mem- 
brane. During  this  application,  an  injection  of  the  aqueous  mixture 
above  mentioned  is  to  be  made.  Finally,  the  parts  are  washed  in  cold 
water. 

Doubtless  this  proceeding  is  easier  and  more  certain  in  men  than  in 
women;  yet  it  is  applicable  to  the  latter,  in  the  form  of  injections  of  the 
mixture  into  the  vagina,  or,  of  applications  of  the  pure  liquor  on  a  piece 
of  linen  held  between  the  labia  majora  and  minora. 

But  even  if  our  enthusiastic  expectations  are  not  all  realized,  and  the 
hope  of  the  final  suppression  of  syphilis  in  a  future  day  be  only  a  beauti- 
ful dream,  M.  Rodet  will  certainly  have  rendered  a  signal  service  to 
humanitv,  if,  thanks  to  the  preservative  and  to  the  system  of  precaution 
which  its  use  requires,  even  a  considerable  diminution  of  the  chances  of 
contamination  should  be  attained. 

We  ought  to  add  that  M.  Rodet  proposes  his  "liquide  chloruro-fer- 
rique  "  not  merely  as  a  prophylactic  against  syphilis,  but  as  a  cure  for 
the  same  disease.  According  to  his  experiments,  the  liquor  modifies 
simple   and   even   indurated   chancres  with   truly  remarkable   rapidity, 


RECONSTITUENT    REMEDIES.  25 

sometimes  arresting  in  twenty-four  hours  the  power  of  secreting  virulent 
pus. 

Assuredly  these  results  are  worthy  of  ail  the  attention  of  physicians, 
and  we  wish  with  all  our  heart  for  their  confirmation. 

This  application  in  syphilis  has  naturally  been  followed  by  a  similar 
treatment  of  other  virulent  diseases.  M.  Rodet,  assisted  by  his  brother, 
a  distinguished  veterinarian  of  Lyons,  has  made  a  series  of  experiments 
with  the  object  of  destroying  the  virus  of  rabies  and  of  glanders  intro- 
duced by  inoculation,  and  he  seems  to  have  obtained  quite  conclusive 
results  with  his  liquid. 

But  as  regards  hydrophobia,  prudence  directs  a  reserve  of  opinion; 
until  the  demonstration  is  complete,  it  will  be  better  to  first  burn  the  bite 
with  red-hot  iron,  and  afterwards,  if  there  is  opportunity,  the  liquid  may 
be  made  to  penetrate  the  remoter  parts  of  the  wound,  which  the  iron 
could  not  reach. 

We  shall  further  mention  the  application  of  the  preservative  to  poi- 
sons, especially  that  of  the  viper;  but  it  is  plain  that  success  must  depend 
on  a  very  speedy  application,  on  account  of  the  exceptional  rapidity  with 
which  absorption  occurs. 

The  chances  of  success  will  be  much  greater  in  the  case  of  bites  of 
gnats,  wasps,  bees,  etc.;  it  cannot  be  too  highly  recommended  in  the 
bites  of  certain  flies  which  so  often,  in  summer,  occasion  charboii. 

The  preservative  liquor  is  specially  recommended  by  Dr.  Pctrequin,  in 
dissection  wounds. 

Internal  use. — Great  as  has  been  the  extension  of  the  external  use  of 
perchloride  of  iron,  its  internal  use  has  been  equally  enlarged. 

Its  usefulness  as  a  haemostatic  naturally  suggested  its  application  to 
the  treatment  of  internal  hiBmorrhages.  It  has  in  fact  been  used  from 
the  first,  in  haemoptysis,  gastrorrhagia,  and  certain  intestinal  hjemorrhages. 

The  results  obtained  in  these  various  cases  were  often  good,  but  they 
were  improved  when  tlie  time  for  administration  was  better  understood; 
this  should  be  as  distant  as  possible  from  the  haemorrhagic  molimen,  es- 
pecially in  active  hcemoptysis. 

By  degrees  the  remedy  has  been  applied  in  most  of  the  great  internal 
hoemorrhages,  and  it  is  now  daily  given  in  metrorrhagia,  whether  essen- 
tial or  symptomatic  of  various  organic  lesions.  In  all  these  it  is  very 
useful. 

We  can  say  as  much  for  leucorrhcBa,  blennorrhagia  at  the  period  of 
decline,  and  a  great  many  affections  of  the  mucous  membranes  which  are 
accompanied  by  bloody  or  mucous  fluxes. 

We  have  successfully  used  perchloride  in  certain  cases  of  severe 
dysentery,  at  an  advanced  stage,  when  all  ordinary  means  had  entirely 
failed. 

The  perchloride  has  particular  efficacy  in  purpura,  whether  of  the 
variety  simplex  or  hgemorrhagica. 

A  distinction  is  to  be  observed  in  regard  to  purpura  simplex.     Accord- 


26  THERAPEUTICS. 

ing'  to  M.  Devergie,  if  it  presents  irregular  plaques,  diffused,  always  quite 
large,  especially  if  its  progress  is  continued  and  progressive,  the  per- 
chloride  rapidly  cures  it.  If  the  spots  are  generally  lenticular  or  petechial, 
quite  circumscribed,  and  appear  in  successive  crops,  the  case  is  otherwise, 
and  the  effect  may  be  to  shorten  each  attack  a  little;  but  it  does  not  pre- 
vent relapses  or  further  crops,  and  in  fine  exercises  but  a  very  slight  in- 
fluence upon  the  mode  of  development  and  the  total  duration  of  the 
disease. 

In  purpura  h<emorrhagica,  on  the  contrary,  a  deeper  and  more  serious 
affection,  characterized  by  haemorrhages  from  various  mucous  surfaces, 
the  perchloride  possesses  great  power.  In  this  respect  the  observations 
of  M.  Pize  of  Montelimart,  and  a  certain  number  of  other  practitioners, 
seem  very  conclusive. 

Yet  it  would  be  a  grave  mistake  to  attribute  infallibility  to  the  rem- 
edy, on  account  of  its  successes.  For  the  disease,  though  putting  on  the 
same  form,  may  have  radical  differences;  and  further,  it  often  gets  well 
with  marvellous  rapidity,  whether  a  certain  treatment  be  followed  or  no; 
and  often,  on  the  contrary,  it  goes  straight  on  to  a  fatal  end.  We  require 
no  facts  to  show  the  inellicacy  of  the  pretended  specific  in  these  refrac- 
tory cases. 

Being  a  martial  preparation,  the  perchloride  naturally  has  some  use  in 
the  treatment  of  an;tmia  and  chlorosis.  At  the  close  of  the  last  century, 
it  was  combined  with  Hoffmann's  solution,  and  enjoj^ed,  under  the  name 
of  Bestuchef's  tincture,  a  great  reputation,  being  thought  to  woi-k  won- 
derful cures,  as  a  tonic  and  antispasmodic.  Recent  trials  have  shown  the 
efficacy  of  the  preparations  of  perchloride  of  iron  in  affections  marked  by 
impoverishment  of  the  blood.  In  its  double  form  of  reconstituent  and 
astringent  it  seems  to  me  that  it  ought  to  find  a  special  indication  in 
menorrhagic  chlorosis.  Thus  it  will  prove  of  special  use  to  a  certain 
number  of  young  girls  just  beginning  to  menstruate,  in  whom  the  first 
periods  are  real  lia?raorrhages. 

Under  these  conditions,  we  have  more  than  once  had  occasion  to  ob- 
serve good  results  from  the  employment  of  the  solution,  during  the 
hsemorrhagic  crisis,  with  cinchona  powder  in  the  intervals,  as  a  means  of 
rendering  the  new  function  regular  at  its  outset,  and  of  preventing  sub- 
sequent fresh  accidents. 

We  have  now  to  speak  of  the  use  of  perchloride  of  iron  in  diphtheria. 
On  account  of  the  special  interest  of  this  question,  we  shall  dwell  upon  it 
at  some  length. 

Dr.  Aubrun  is  entitled  to  all  the  credit  of  originating  this  treatment. 
Our  respected  confrere,  thanks  to  the  skill  and  perseverance  Avith  which 
he  has  pursued  his  course  of  experiments,  has  developed  a  complete  new 
method  of  treatment  in  croupous  angina,  which  may  have  its  future. 

The  method  is  as  follows: 

If  diphtheria  of  the  pharynx  exists  from  the  outset,  we  begin  by 
touching  the  back  of  the  throat  with  a  sponge  dipt  in  an  aqueous  solution 


EECONSTITUENT    REMEDIES.  27 

of  perchloride  of  iron  of  various  strength.  The  liquor  of  Dr.  Rodet  may 
deserve  preference.  The  operation  is  immediately  followed  by  increased 
ease  of  breathing,  due  to  removal  of  the  false  membranes  from  the  phar- 
ynx; and  at  the  same  time  it  acts  as  an  alterative  upon  the  affected  parts. 
It  will  be  necessary  to  repeat  this  several  times,  according  to  the  severity 
of  the  local  affection,  and  especially,  according  to  the  ease  with  which  the 
false  membranes  are  detached. 

Contrary  to  general  opinion  and  practice,  M.  Aubrun  assigns  only  a 
very  secondary  place  to  topical  applications,  and  hardly  insists  on  their 
use  ;  but  we  cannot  share  this  view,  which  is  too  exclusive.  He  considers 
that  all,  or  nearly  all  the  treatment  consists  in  the  internal  use  of  per- 
chloride of  iron. 

He  attaches  great  importance  to  the  method  of  administration.  If  the 
patient  is  a  child,  20  drops  of  perchloride  liquid  at  30°  are  placed  in  a 
glass  of  cold  water.  Of  this,  the  patient  drinks  a  swallow  (about  two 
teaspoonfuls)  every  five  minutes  while  awake,  and  every  quarter  of  an 
hour  during  the  time  of  sleep.  Immediately  after  each  swallow,  the  child 
is  made  to  swallow  a  mouthful  of  cold  milk,  not   boiled,  without  sugar. 

M.  Aubrun  advises  that  this  treatment  be  continued  with  scrupulous 
regularity  several  days  in  succession,  without  pausing  during  sleep  in  the 
first  three  days,  at  least  in  very  grave  cases.  His  reason  for  this  persist- 
ence is,  that  the  false  membranes  do  not  usually  begin  to  soften  and  fall 
off  before  the  end  of  the  third  day. 

It  is  necessary  to  take  the  precaution  of  giving  the  solution  in  a  glass 
or  porcelain  cup,  and  not  in  a  metal  spoon  or  vessel,  in  order  to  prevent 
decomposition.  It  is  also  necessary  to  avoid  all  drinks,  medicines  or  foods 
which  might  effect  this  decomposition,  and  more  particularly  those  con- 
taining tannin.  In  fine,  the  treatment  for  the  first  four  or  five  days  is 
almost  wholly  confined  to  the  solution  of  perchloride,  which  varies  from  20 
to  40  drops  to  the  glass  of  water  (according  to  the  patient's  age)  and  to  cold 
milk.  In  general  the  patient  takes,  every  24  hours,  from  seven  to  ten  glasses 
of  the  solution  (1^ — 2  litres  =  3 — 4  pints),  and  nearly  as  much  milk,  making 
from  140  to  360  drops  of  the  perchloride  in  24  hours.  M.  Aubrun  advises 
that  the  treatment  be  commenced  as  soon  as  possible  after  the  outbreak 
of  the  diphtheritic  affection,  in  order  to  arrest  its  progress  more  surely. 

In  support  of  this  new  treatment  M.  Aubrun  presents  the  following 
results,  all  taken  from  his  own  practice  : 

During  three  years  he  has  employed  it  upon  39  patients,  of  whom  35 
were  cured — 2  with  tracheotomy.     The  cases  are  classified  as  follows  : 

25  affected  the  pharynx  from  the  outset. 25  cures, 

5        "        pharynx  and  skin  from  the  outset 5       " 

„  C  d  from  the  outset 3       " 

9  the  pharynx  and  larynx;  i  /.      ^  ,  ■, 

^      /.      ,                        '  •<  b    at    an  advanced    pe- 
generahzed;  severe;         j      ^..^^ ^       « 

39  35 


28  THERAPEUTICS. 

The  two  last  cures  were  obtained  by  tracheotomy  (  Union  medicale, 
22  decembre,  1860). 

These  are  certainly  most  remarkable  results,  which  must  prepossess  us 
in  favor  of  the  new  system. 

The  same  treatment  has  been  used  by  others,  both  in  Paris  and  the 
provinces,  and  several  have  had  good  results.  We  add  that  one  of  us 
very  lately  employed  it  very  successfully  in  the  case  of  a  little  girl,  se- 
verely affected. 

After  M.  Aubrun,  we  will  specially  cite  M.  Isnard  of  St.  Amand,  as 
having  given  most  attention  to  the  subject.  In  our  oj^inion,  this  gentle- 
man deserves  the  credit  of  having  very  clearly  grasped  and  very  judicious- 
ly estimated  the  mode  of  action  of  the  perchloride. 

M.  Isnard  sums  up  the  action  of  perchloride  of  iron  as  follows: 

1.  Action  on  the  blood,  the  fibrino-albuminous  elements  of  which  it 
renders  more  plastic,  and  prevents  their  transudation  through  the  respira- 
tory mucous  membrane;  or  later,  in  infectious  cases,  through  the  walls  of 
the  uriniferous  tubules,  cutaneous  wounds,  the  serous  membranes,  etc. 

2.  Action  on  the  respiratory  mucous  membrane,  the  fibrino-albumi- 
nous elements  of  which  it  also  renders  more  plastic,  and  contracts  the  or- 
ganic frame-work.  Thus  the  mucous  membrane  becomes  incapable  of 
being  traversed  by  the  albuminoid  principles  of  the  blood. 

3.  Tonic  corroborant  action  upon  the  nervous  system,  the  essential 
action  in  the  view  of  most  physicians;  unquestionable,  but  of  very  second- 
ary importance  in  the  direct  treatment  of  croup. 

Resting  upon  the  results  which  have  been  already  gained,  and  per- 
haps still  more  upon  the  argument  drawn  from  this  triple  influence,  M. 
Isnard  does  not  hesitate  to  consider  perchloride  of  iron  our  hope  in  crovip, 
and  in  some  sort  its  specific  cure.  He  explains,  however,  his  view  as  to 
specificity.  Perchloride  of  iron  is  not,  he  say.s,  an  anti-diphtheritic 
specific  in  the  full  acceptation  of  the  term  ;  but  it  prevents  the  intoxi- 
cation. It  does  not  destroy  existing  infection,  but  it  arrests  it  in  its  in- 
creasing progress,  and  thus  gives  to  the  organism  the  faculty  of  reacting, 
of  throwing  off  the  toxic  principle  by  its  own  forces  and  the  natural 
emunctories  (  Union  medicale,  sept.,  1859). 

This  interpretation  is  not  quite  complete,  but  seems  to  us  rational 
and  true;  at  least,  it  has  the  merit  of  giving  the  living  organism  its  fair 
dues,  in  a  special  question  of  therapeutics  where  modern  chemistry  con- 
siders itself  alone  entitled  to  interfere,  and  vitalism  quite  out  of  court. 

AVe  should  mention  a  similar  attempt,  previous  to  M.  Aubrun's,  in 
■which  the  perchloride  was  used  in  a  purely  topical  manner.  We  refer  to 
the  distinguished  Dr.  Jodin  of  Paris,  who,  having  followed  the  studies  of 
M.  Bazaine  on  tinea,  struck  with  the  contagious  property  of  the  false 
membrane,  asked  himself  whether  the  latter  might  not  be  wholly  com- 
posed of  a  parasite. — He  found  spores  and  parasitic  tubes  in  the  false 
membrane  of  the  throat  and  trachea;  but,  though  the  fact  is  correct,  it  is 
to  be  feared  that  the  interpretation  is  wrong,  for  he  himself  candidly 


EECONSTITUENT    REMEDIES.  29 

states  that  he  found  the  same  parasites  in  the  mouth,  even  when  the  pa- 
tients were  affected  with  other  diseases.  It  follows  that  these  spores  are 
no  more  characteristic  of  the  false  membranes  than  thrush  is  of  phthisis. 

The  useful  point  in  Jodin's  observations  is,  the  great  utility  of  local 
cauterization  of  the  false  membranes.  It  is  only  necessary,  in  order  to 
make  this  effectual,  to  press  upon  the  false  membrane  in  order  to  satu- 
rate it  well,  and  cauterize  it  in  its  entire  depth. 

This  treatment  has  been  since  employed  with  success  by  Courty 
("Recherches  sur  les  conditions  meteorologiques  et  le  traitement  de  la 
diphtheric,"  Montpellier,  18G3),  and  by  M,  Leroi,  of  Chateau-du-Loir 
( Union  medicale,  18G0), 

Very  recently  a  naval  surgeon,  Dr,  Noury,  has  confirmed  these  re- 
sults by  the  cure  of  twelve  out  of  thirteen  patients  with  angina  diphthe- 
ritica. He  reports  that  Dr.  Cuneo,  at  the  port  of  Toulon,  has  more  than 
20  similar  cures.  These  gentlemen  carried  the  doses  up  to  10  grammes 
(154  grains)  per  day,  even  in  a  child  of  5  years  (Noury:  These  de  Paris, 
1872,  No.  62). 

In  fine,  while  acknowledging  the  first  successes  of  the  new  treatment 
of  diphtheria,  we  must  leave  to  time  the  duty  of  giving  final  judgment. 


Toxic  Treatment  ix  General. 

We  shall  see  alterative  medicine  hindering  or  destroying  the  action 
of  the  plastic  force,  opposing  the  reparative  clianges  of  living  chemistry 
by  weakening  the  nutritive  properties  of  the  blood  and  the  tonicity  of 
the  solids.  Tonic  medication  has  an  entirely  different  object;  it  restores 
the  tonicity  of  the  tissues,  reconstitutes  the  assimilative  functions,  and 
imparts  vital  resistance  to  the  system. 

If  we  consider  the  organic  actions  directly  affected,  we  shall  soon  find 
that  they  are  the  most  important,  the  most  radical  in  the  system,  and  the 
basis  of  animal  life.  They  are  found  in  the  lowest  and  simplest  of  ani- 
mals, as  complete,  as  perfect,  as  well  marked  in  essential  points,  as  in  the 
highest  animals,  or  even  in  man. 

As  observed  in  animals  which  consist  of  a  formless  parenchyma  con- 
taining an  alimentary  sac  without  any  other  special  organ,  the  actions 
here  considered  comprise  essentially:  1,  an  areolar  circulation  which  re- 
quires two  conditions,  viz.:  an  organizable,  assimilable  liquid,  and  a  solid 
matter  possessing  a  certain  orgasm  or  tonicity,  which  enables  it  to  react 
against  the  impression  of  the  liquid,  its  normal  excitant,  so  as  to  perform 
obscure  movements  in  various  ways  (capillary  or  interstitial  circulation) ; 
2,  identification  of  an  assimilable  liquid  with  the  assimilant  solid  (nutri- 
tion); 3,  the  formation  at  the  point  of  contact  of  these  two  elements,  of 
a  new  product  (secretion),  which,  not  being  further  required  as  a  part  of 
the  creature,  is  soon  eliminated  (excretion) ;  4,  the  production  of  a  spe- 
cial temperature  (calorification). 


30  THERAPEUTICS. 

This  extreme  simplicity  corresponds  with  the  simplicity  and  homo- 
geneity of  the  composition  of  these  animals,  which  consist  only  of  cells 
which  are  nearly  alil<e.  Living  chemistry  had  few  combinations  to  make 
in  forming  a  single  substance,  the  least  animalized  in  the  scale  of  tissues. 
This  is  why  these  animals  contain  no  elaborating  organs,  viscera,  for  pre- 
paring the  food  and  rendering  it  fit  to  repair  the  organized  matter. 

But  in  higher  animals,  mammals,  and  man  esjDecially,  to  whom  all  that 
we  are  now  to  say  relates,  the  system  of  nutrition  is  infinitely  complex. 

In  finishing  the  animal,  nature  has  reached  the  highest  degree  of 
organic  perfection,  which  consists  in  the  summum  of  development  of  the 
organs  which  place  it  in  relation  with  all  other  beings.  The  instruments 
of  this  "life  of  relation"  are  the  cerebro-spinal  system  of  nerves  and  the 
locomotor  muscular  system,  both  formed  of  the  most  composite  and  the 
most  animalized  tissues  in  general  anatomy,  albumin  and  fibrin. 

"The  animal  lives  for  the  nervous  system,"  says  a  great  naturalist. 
We  shall  deduce  from  this  profound  saying  the  fundamental  principle 
which  we  think  ought  to  guide  the  pathologist  in  the  philosophic  study 
of  tonic  medicine. 

In  man,  a  series  of  instruments  or  organs  called  viscera  (from  vescor, 
I  am  nourished)  stands  between  the  food  and  the  organized  matter,  the 
function  of  which  is  to  give  to  the  food  a  series  of  modifications  which 
assimilate  it  to  the  substances  which  it  is  to  form  or  support.  Another 
series  of  organs  has  the  object  of  elaborating,  not  reparative  substances, 
but  the  unassimilable  parts  of  food,  and  the  substances  which,  used  by 
organic  movement,  and  super-animalized,  are  to  be  rejected.  Thus,  be- 
tween the  injresta  and  the  fixed  animal  matter,  there  is  a  series  of  assimi- 
lant  or  composing  organs;  between  the  fixed  matter  and  the  excrements, 
a  series  of  depurative,  disassimilant,  decomposant,  excretory  organs.  This 
constitutes  the  nutritive  system,  the  organic  life,  in  man.  This  complex- 
ity is  necessary,  in  order  that  the  alimentary  material  may  pass  gradually 
into  a  state  of  animalization  such  that  they  may  replace  the  various  com- 
ponents of  the  human  body.  In  the  last  analysis,  all  these  preparatory 
operations  of  vital  chemistry,  acting  through  the  viscera  of  assimilation 
and  disassimilation,  do  nothing  but  prepare  the  formation  of  the  organs 
of  the  life  of  relation,  to  wit,  the  cerebro-spinal  nervous  system  and  the 
muscular  system  which  is  subject  to  it. 

But  a  spinal  nervous  system  is  required  to  animate  all  these  organs 
and  co-ordinate  their  functions.  These  functions  seek  one  end  by  vari- 
ous means;  they  require  an  influence  to  distribute  to  them  such  degree 
of  sensibility  as  may  place  them  in  connection  with  their  special  stimu- 
lus, and  may  cause  in  them  the  movements  necessary  for  transporting 
nutritive  and  effete  materials;  an  influence  which  may  insure  the  unity 
and  regularity  of  the  operations,  and  which,  establishing  a  correspon- 
dence with  the  sensible  centre,  the  brain,  may  inform  the  animal  of  his 
needs,  and  urge  him  by  irresistible  instincts  to  procure  food.  This  ner- 
vous system  is  called  the  great  sympathetic  or  trisplanchnic. 


EECONSTITUENT   REMEDIES.  31 

Three  chief  things  are  to  be  considered  in  the  nutritive  system  of  man, 
Avhich  is  called  by  Bichat  the  organic,  interior,  or  hidden  life  of  man.  These 
three  are  of  much  importance  in  relation  to  tonic  medicine,  and  are: 

1.  The  fixed  and  solid  animal  matter,  organic  tissues,  parenchyma,  etc.; 
2,  the  liquid  animal  matter  from  which  the  solids  draw  all  the  elements 
of  their  development,  maintenance,  and  repair;  3,  the  nervous  system 
which  animates  and  co-ordinates  the  functions  of  the  viscera  which  form 
blood  and  remove  the  residual  and  effete  matters. 

Let  us  apply  these  physiological  facts  to  the  study  of  tonic  medication. 

1.  We  have  seen  that  the  organic  tissues,  in  order  to  receive  the  im- 
pression of  the  nutritive  fluids  circulating  in  their  interstices,  need  a 
certain  power  which  shall  enable  them  to  react  on  these  fluids  and  give 
them  the  oscillatory  movements  which  constitute  the  areolar  or  capillary 
circulation,  and  shall  also  give  them  a  vital  affinity  for  the  circulating 
fluid,  to  enable  them  to  borrow  from  it  the  molecules  needed  for  its  sus- 
tenance; that  is,  a  power  of  assimilating  the  fluid. 

This  important  faculty  has  always  fixed  the  attention  of  physiologists. 
Stahl,  who  was  greatly  interested  in  it,  gave  to  it  the  government  of  many 
physiological  and  pathological  acts  which  do  not  belong  to  it;  he  called 
it  tonicity  or  tonic  movement  (from  tovos,  tone,  tension,  rigidity).  "  Motus 
vitales  teque  parte  animales  uti  ante  omnia  supponunt  sufficiens  robur  in 
ipsa  parte,  quod,  quia  in  certa  tensione  consistit,  propterea  tonum  appel- 
lare  soleo,  et  maximo  merito  motum  tonicum  "  (Stahl:  "  Theor.  med.  ver.," 
p.  647).  Bichat,  decomposing  the  properties  of  this  force,  gives  it  the 
double  name  of  organic  sensibility  and  insensible  organic  contractility. 
Lamarck  ("  Philosoph.  zoolog.")  speaks  long  and  very  well  of  it,  denoting 
it  by  the  word  orgasm,  which  in  fact  seems  to  us  very  exact.  Broussais 
("  Physiol,  appl.  a  la  pathol.")  calls  it  vital  erection,  and  his  study  has  given 
him  material  for  admirable  developments. 

Recent  biological  experiments  (which  throw  so  great  a  light  on  all 
which  concerns  ph^'siology,  and  even  pathology)  have  shown  by  the  labors 
of  Prochaska,  Legallois,  Marshall  Hall,  Joh.  Miiller,  Claude  Bernard,  etc., 
that  this  tonic  action  originates  in  the  sensitive  nervous  terminations, 
passes  to  the  medulla,  and  returns  thence  to  the  same  or  another  point 
as  a  motor  excitation,  whence  the  epithet  reflex  is  given  to  this  action. 

The  anatomical  base  of  this  act  was  discovered,  in  1853,  by  Schroeder 
van  der  Kolk,  at  Utrecht,  and  "Wagner,  at  Gottingen.  The  posterior  roots 
of  the  spinal  cord  furnish  one  group  of  ascending  fibres  which  go  to  the 
encephalon,  a  second  which  loses  itself  in  the  posterior  cornu,  and  a  third 
which  passes  from  behind  forward  through  the  entire  thickness  of  the  cord 
and  goes  to  the  groups  of  large  motor  cells,  and  thence  to  the  motor  nerves 
(Jaccoud:   "  Les  paraplegics  et  I'ataxie  du  mouvement,"  1864). 

M.  Claude  Bernard  has  further  shown  that  the  excito-motor  arc  does 
not  necessarily  pass  through  the  cord,  and  that  a  ganglion  of  the  great 
sympathetic  may  serve  as  a  centre  of  reflex  action.  He  has  demonstrated 
this  upon  the  submaxillary  gland. 


32  THEEAPEUTICS. 

This  established,  let  us  add  that  certain  very  grave  morbid  conditions 
are  specially  characterized  by  a  loss  or  considerable  enfeeblement  of  this 
faculty,  a  sensible  relaxation  of  the  tonicity  of  the  living  tissues;  the  sensi- 
bility and  the  insensible  contraction  of  the  parenchyma — to  use  the  words 
of  Bichat — are  so  languid  and  lose  so  far  their  affinit}'  for  the  blood  and 
other  liquids,  their  normal  stimulus,  that  the  affinities  of  vital  chemistry 
are  no  longer  set  in  action.  In  these  affections  the  capillary  circulation 
is  slow  and  imperfect,  and  the  liquids  are  as  much  under  the  control  of 
gravity  as  of  contractility.  They  escape  through  the  exhalants,  transude 
by  the  pores,  spread  over  the  surfaces,  or  are  extravasated  in  the  cellular 
cavities,  etc.  These  accidents  are  the  predominant  ones;  their  indications 
are  the  most  pressing,  often  the  only  ones.  There  is  a  class  of  tonic  agents 
suited  to  combat  these  accidents  and  fulfil  these  indications;  these  are  the 
tonics,  properly  so  called,  in  the  strict  etymological  sense  (tovos,  tension). 

Some  writers  on  materia  medica  exclude  these  from  the  general  class 
of  tonics,  and  place  them  apart  as  astringents.  We  prefer  to  follow  Cul- 
len  and  others,  who  place  them  among  tonics,  under  the  name  of  astrin- 
gent tonics. 

Thus,  tonics  in  general  are  divided,  firstly,  into  astringent  tonics,  which 
give  to  the  solids,  directly,  the  tone,  orgasm,  vital  density,  needful  for  the 
performance  of  their  insensible  actions. 

2.  The  blood,  the  internal  source  of  supply  whence  the  solids  draw  all 
the  elements  of  development,  sustenance  and  repair,  in  order  to  possess 
these  qualities,  must  convey  a  sufficiency  of  nutritive  particles,  of  liquid 
flesh,  in  a  word,  of  fibrin,  albumin,  globules,  etc.  There  are  diseases  spe- 
cially characterized  by  an  insufficiency  of  the  elements,  which  give  rise  to 
a  o-reat  variety  of  the  severest  symptoms.  The  most  important  indication 
is  to  restore  to  the  blood  its  nutritive  qualities  as  soon  as  possible.  The 
remedies  which  effect  this  are  called  analeptic  or  reconstituent  tonics  (from 
dvaXa/jL-ISdvoi,  I  re-establish). 

The  second  division,  then,  consists  of  analeptic  tonics,  characterized 
by  restoring  immediately  to  the  blood  the  organizable  and  reparative 
principles  which  are  lacking. 

3.  Lastlv,  the  nervous  system  which  animates  and  co-ordinates  the 
functions  of  the  viscera  which  form  the  blood,  remove  residuary  and 
effete  matters,  and  preside  over  generation,  the  ganglionic  system,  in 
order  to  perform  those  important  functions,  needs  energetic,  persistent, 
active,  constant  and  profound  energy,  and  especially,  perfect  harmony  of 
action.  This  system  governs  the  phenomena  of  animalism.  It  regulates 
all  the  instincts,  all  the  phenomena  of  vital  synergy,  of  general  reaction, 
of  the  vis  medicatrix,  of  physiological  resistance — in  a  word,  all  those 
great  phenomena  on  which  rest  health  and  the  symptoms  in  disease.  The 
principal  centres  of  this  apparatus  are  what  has  been  designated  by  turns 
the  evopfiov,  the  duumvirate,  the  archreus,  the  impetum  faciens,  the  vital 
tripod,  etc. 

Every  considerable  disease  has  its  echo  in  this  system.     It  is  usually 


RECONSTITUENT   KEMEDIES.  83 

affected  indirectly.  In  certain  cases  it  is  attacked  partially  and  primarily; 
with  these  we  have  not  to  deal.  But  certain  other  causes  strike  directly 
the  chief  foci  of  this  system,  and  tend  to  extinguish  organic  life  in  its 
animatinsT  centres.  Then  we  see  all  the  erreat  functions  of  the  economy 
fall  into  sudden  collapse  and  incoherence;  strength  and  harmony  are 
broken,  the  synergies  impotent,  vital  resistance  blasted,  the  principle  of 
existence  directly  threatened.  These  are  the  malignant,  pernicious  mal- 
adies, etc.  We  then  need,  to  save  the  life  which  is  ready  to  flee,  heroic 
remedies,  which  do  not  require  to  excite  one  or  several  physiological 
modifications  before  their  effect  is  produced,  but  go  straight  to  the  point 
of  danger,  attack  the  enemy  body  to  body,  as  Galen  says,  and  throw  him 
violently;  or  rather,  which  resist  with  energy,  and  support  the  nervous 
system  in  its  reaction  against  the  fatal  influence  of  certain  causes  or 
morbid  germs.  The  last  class  of  tonics  includes  these  potent  antagonists, 
which  we  will  name  neurosthenic  tonics. 

The  third  division,  therefore,  consists  of  neurosthenic  tonics,  char- 
acterized by  conferring  vital  resistance  immediately  upon  the  living  forces 
of  the  animal  system,  and  by  re-establishing  its  synergies. 

Independently  of  these  special  and  distinct  effects,  the  above  classes 
of  remedies  have  a  tonic  action  in  common,  resulting-  from  their  usual 
mode  of  administration.  All  of  them,  when  placed  in  the  stomach,  are 
stomachics,  excepting  some  of  the  first  class;  and  the  restoration  of  di- 
gestive power,  insuring  good  material  for  repair,  is  certainly  a  leading 
and  very  powerful  sort  of  tonic  action.  And  who  does  not  know  that  the 
physiological  influence  of  a  stomach,  which  is  happily  at  work,  pacifies 
and  consoles  the  whole  system,  giving  a  proof  that  force  and  harmony 
are  there,  "pylorus  rector"  (Van  Helmont)  ? 

The  study  of  remedies  has  two  parts:  1,  that  of  the  physiological  or 
immediate  action  of  a  class  of  remedies;  2,  that  of  the  indications  or  con- 
tra-indications  for  producing  this  action  in  given  diseases. 

We  will  resume  the  study  of  tonic  medication  in  general  upon  this 
plan. 

Physiological  or  immediate  action  of  tonics. — In  order  to  understand 
the  immediate  effects  of  a  remedy  they  must  be  observed  in  a  person  in  a 
state  of  perfect  health,  whose  organs  are  all  in  equilibrium  and  possess 
their  vital  reaction.  If  we  recall  what  was  just  said,  and  define  tonics  in 
general  as  remedies  capable  of  restoring  energy  to  the  functions  of  or- 
ganic life  directly  and  immediately,  we  shall  soon  see  that  they  do  not 
possess  a  physiological  action  differing  from  their  therapeutic  one.  Ob- 
serve, also,  that  we  do  not  say  that  they  give,  but  that  they  restore 
energy  to  these  functions.  How  could  energy  be  given  to  the  nutritive 
functions  of  a  man  who  lacks  no  energy  ?  In  order  that  the  effect  of 
tonics  should  be  marked,  the  function  must  first  be  feeble  and  stand  in 
need  of  restoration. 

Properly  speaking,  there  will  be  no  physiological  action.  Let  us  ex- 
plain. A  mustard  foot-bath  is  prescribed  in  active  congestion  of  the 
8 


34  THERAPEUTICS. 

brain.  The  redness,  pain,  congestion,  in  a  word,  irritation  of  the  feet, 
form  the  physiological  action  of  the  bath.  If  the  congestion  of  the  head 
is  arrested  by  the  effect  of  the  mustard,  that  is,  by  the  revulsive  irrita- 
tion of  the  limbs,  the  therapeutic  aim  is  attained.  It  is  very  important 
to  note  the  distinction  between  the  two,  for  the  former  may  easily  exist, 
and  unhappilv  does  often  exist,  without  the  latter  :  whence  the  great  un- 
certainty of  therapeutics.  When  a  remedy  possesses  all  its  physical  and 
chemical  properties,  is  in  good  condition,  is  given  in  fit  doses,  we  gener- 
ally get  from  it  the  physiological  action  of  which  it  is  capable.  It  is  far 
from  being  so  with  the  remote,  mediate,  or  therapeutic  action.  The  cura- 
tive effect  is  always  preceded  by  a  vital  action  kept  up  by  the  remedy, 
to  which  we  apply  the  name  of  immediate  or  physiological  effect. 

This  effect  sometimes  appears  in  other  organs  than  those  which  re- 
quire to  be  affected,  and  it  then  appears  distinct  from  the  remote  or  ther- 
apeutical effect.  At  other  times  the  remedy  has  its  special  influence  di- 
rectly upon  the  vital  acts  which  are  aimed  at;  in  this  case  the  immediate 
or  physiological  action  seems  to  be  confounded  with  the  remote  or  cura- 
tive effect.  J3ut  in  reality  the  two  orders  of  effects  always  exist,  and 
the  second,  the  one  desired,  is  always  indirect,  that  is,  the  product  of  life 
modified  by  the  remedy.  There  exist  no  specifics  in  the  sense  of  the 
Galenists  and  of  humoral  medicine.  The  medicine  either  acts  on  the  af- 
fected organ,  and  is  direct,  or  upon  a  different  one,  and  is  indirect.  In 
both  cases  tlie  malady  is  never  modified  except  by  the  intervention  of  a 
physiological  action. 

To  this,  finally,  does  the  division  into  rational  and  specific  treatment 
come,  which,  we  repeat,  is  only  a  Galenic  subtlety. 

All  writers  on  materia  medica  have  assigned  to  tonics  the  character 
of  acting  insensibly,  gradually,  and  of  imparting  to  the  vitality  of  the  or- 
gans a  durable  energy.  Upon  this  fact  they  base  the  distinction  between 
tonics  and  stimulants;  the  latter  acting  promptly,  vigorously,  and  with  an 
evident  vital  exaltation,  which  is  unmistakable,  though  very  transient. 
These  facts  are  a  proper  basis  for  drawing  a  natural  distinction,  but  we 
may  go  further,  and  ask  for  the  reasons  for  this  difference. 

Several  illustrious  physicians  of  the  school  of  Montpellier,  Barthez  and 
Dumas  in  particular,  have  admitted  two  species  of  forces  in  the  system — 
the  acting  forces,  in  actu,  and  the  radical  forces,  or  in  posse,  a  distinction 
already  pointed  out  by  Galen. 

Since  an  understanding  of  this  distinction  is  indispensable  in  order  to 
grasp  the  action  of  the  most  important  tonics,  we  shall  leave  to  Barthez 
himself  the  task  of  stating  it;  we  shall  develop  it  when  applying  it  to 
special  classes  of  cases. 

"  We  ought  not  to  regard  the  system  of  the  forces  of  the  vital  princi- 
ple as  we  do  those  of  the  mechanic  forces.  This  error  produces  an  in- 
finity of  others,  in  the  science  of  man  and  in  practical  medicine. 

"  A  system  of  mechanical  forces  includes  only  determined  forces 
which  act  at  a  given  time  to  produce  equilibrium  or  sensible  motion. 


RECONSTITUENT    REMEDIES.  35 

"  But  among  the  forces  of  the  vital  principle  we  must  distinguish  the 
forces  which  this  principle  causes  to  act  at  each  moment  in  all  the  organs, 
from  the  radical  forces,  or  those  which  have  the  power  to  sustain  the  act- 
ing forces  in  their  task, 

"  The  aggregate  of  the  sums  of  these  two  sorts  of  forces  forms  that 
which  I  call  the  entire  system  of  the  forces  of  the  vital  principle. 

"No  doubt  it  is  hard  for  us,  with  our  mechanical  notions,  to  imagine 
a  sort  of  forces  which  are  absolutely  radical  or  potential. 

"  But  in  support  of  this  distinction,  which  I  am  the  first  to  propose, 
I  remark  that  it  has  always  been  presupposed,  although  in  an  implicit 
and  extremely  vague  way,  since  it  has  always  been  said  to  be  very  desir- 
able in  medicine  to  distinguish  the  oppression  from  the  resolution  of 
forces. 

"  We  can  form  no  idea  of  the  latter  distinction  except  as  we  suppose 
that  radical  forces  exist,  which  are  either  merely  oppressed,  or  are  re- 
solved (destroyed)  in  the  various  cases  of  enfeeblement  of  acting  force. 

"  The  forces  acting  in  the  organs  originate  in  the  radical  forces,  which 
are  distributed  to  each  organ  in  accordance  with  unknown  primordial 
causes,  or  with  causes  extrinsic  to  the  living  body,  which  act  in  a  manner 
only  known  to  us  by  observation. 

The  primitive  energy  of  the  radical  forces  is  doubtless  different  in  each 
man  from  birth,  and  is  susceptible  of  continual  increase  and  decrease. 

"  The  increment  is  effected  directl}^  by  the  action  of  various  fortifying 
agents  which  may  bear  immediately  upon  these  forces.  Some  fortifying 
agents,  such,  for  instance,  as  cinchona,  may  naturally  increase  the  radical 
force  of  the  vital  principle  directly;  and  poisons  may,  equally  naturally, 
attack  and  destroy  directly  these  radical  forces. 

"  But  the  increments  of  radical  force,  which  are  indirectly  produced 
by  an  exercise  of  the  function  which  is  conformable  to  health,  are  of  prin- 
cipal importance.  They  always  exist  in  a  ratio  compounded  of  the  inten- 
sity of  action  displayed  by  the  acting  forces  in  each  of  the  principal  func- 
tions, and  of  the  preservation  of  the  balance  of  activity  among  the  func- 
tions, which  habit  has  established  in  that  form  of  health  which  is  peculiar 
to  each  individual  "  (Barthez:  "  Nouv.  elem.  de  la  sc.  de  l'h.,"t.  II.,  p.  1G3 
et  seq.). 

The  true  tonics,  which  directly  restore  the  functions  of  vegetative 
life  and  impart  vital  resistance  to  the  nervous  system,  bring  their  influ- 
ence to  bear,  immediately,  either  on  the  radical  forces  to  increase  them, 
or  on  the  acting  forces  to  fix  them  and  increase  their  resistance  and  vigor. 
To  use  an  expression,  of  which  the  energy,  conciseness  and  picturesque 
vigor  betray  its  source,  they  make  force,  they  fix  the  state  of  the  body, 
"  vim  porro  habent  ha3c  medicamenta  ut  epotis  his  cokpus  in  loco  sit  " 
(Hippocr.:  "  De  affect."). 

It  is  then  quite  plain  that  they  can  have  no  action  upon  the  healthy 
and  robust  man,  which  can  enable  us  to  prejudge  their  therapeutic  effects. 
The   tonics  we  are  now   considering-  are  those  of  the   second  and  third 


36  THERAPEUTICS. 

class,  the  analeptics  and  the  neurosthenics.  The  former  build  up  the  blood 
directly,  the  latter  by  directly  imparting  vital  resistance  to  the  animal 
frame.  A  man  in  full  vigor  of  function  will  not  be  built  up  by  analeptics, 
because  his  blood  is  already  rich.  He  cannot  go  further  without  endan- 
gering it,  nor  recede  without  impairing  the  assimilative  force  which  is  in 
its  highest  condition  of  activity.  This  has^  been  well  expressed  by  the 
immortal  author  of  the  Aphorisms  as  follows:  "  In  gymnasticte  disciplinge 
deditis,  boni  habitus  ad  summum  progressi  periculosi,  si  in  extremo  ste- 
terint;  non  enim  possunt  in  eodem  statu  manere  neque  quiscere.  Quum 
verononquiescant,  neque  ultra  possint  in  melius  proficere,  reliquum  est  ut 
in  deterius  ruant.  Horum  igitur  causa,  bonum  habitum  solvere  confert 
liaud  cunctanter,  quo  rursus  nutritionis  principium  sumat  corpus,  etc., 
etc."  (Hipp.:  "  Aphor.,"  sect,  i.,  aph,  3). 

If  we  give  to  this  vigorous  man  the  analeptic  tonics,  including  prepa- 
rations of  iron,  the  broths  and  gravy  of  dark  meat,  fibrin,  osmazome,  and 
all  the  substances  which  are  strongly  nitrogenous,  and  if  he  takes  no  food 
except  these,  combined  with  preparations  of  iron,  he  will  soon  be  plagued 
with  symptoms  of  plethora;  then  in  succession,  with  indigestion,  with 
phlegmasias,  haemorrhages,  excessive  diminution  of  all  the  secretions  and 
exhalations,  gravel,  gout,  then  debility,  obliteration  of  the  intellectual, 
sensory  and  motor  faculties,  and  lastly,  indirectly,  remotely,  colliquation 
and  marasmus,  etc.  The  physiological  effects  of  such  remedies  require, 
in  order  to  become  therapeutic  effects,  to  be  developed  in  persons  of  weak- 
ened assimilative  power,  or  whose  blood  has  lost  part  of  its  reparatory 
elements;  for  in  well  and  strong  persons  these  ph^'siological  or  immediate 
effects,  far  from  benefiting  health,  would  only  beget  morbid  symptoms. 
So  true  is  it  that  a  rigorous  classification  of  medicines  is  impossible,  and 
that,  according  to  the  dose  and  the  condition  of  the  subjects,  they  pos- 
sess different,  and  sometimes  opposite  properties. 

If  possible,  the  neurosthenic  tonics  are  still  more  destitute  of  a  physi- 
ological action  in  health  which  could  lead  us  to  infer  their  action  in  dis- 
ease. This  is  evident  as  soon  as  we  name  them — the  bitters,  and  cin- 
chona at  their  head.  To  display  their  power  they  must  attack  a  disease 
or  an  enervated  organism.  How  can  they  impart  vital  resistance,  where 
this  faculty  is  not  impaired  ?  But  give  them  to  persons  in  whom  this  re- 
sistance is  weakened,  threatened,  whose  synergies  are  broken,  discordant, 
and  we  shall  see  how  surely  and  promptly  the  organism  will  rise  and  re- 
sist the  morbid  influence. 

As  to  the  astringent  tonics,  they  form  an  exception  to  these  laws. 
They  always  act  through  tangible  physiological  phenomena,  producible 
on  health,  independently  of  those  changes  in  fibrillar  tonicity  which  form 
the  object  of  their  beneficial  action.  They  are,  therefore,  rather  tonics 
in  the  etymological  than  in  the  medical  acceptation  of  the  word.  We 
have  classed  them  with  tonics  for  this  reason,  and  also  because  they  may 
fulfil  special  indications  in  reconstituent  medicine,  and  thus  become  true 
tonics. 


RECONSTITUENT    REMEDIES.  37 

We  think  that  they  may  act  on  that  which  Bichat  calls  the  properties 
of  the  tissues,  as  distinct  from  vital  properties,  because  they  persist  after 
death.  The  astringent  tonics  may  exhibit  their  corroborant  and  tanning- 
action  upon  tissues  deprived  of  life.  It  is  thus  that  they  are  useful,  and 
affect  immediately  the  vitality  of  such  tissues. 

The  tonic  influence  exercised  by  these  three  classes,  especially  the 
irons  and  the  bitters,  through  their  stomachic  action,  is  obtained  by  physi- 
olo'J-ical  effects,  which  may  to  some  extent  be  seen  in  a  well  person.  In 
such  a  subject,  the  appetite  and  digestion  may  be  excited  and  accelerated, 
but  the  appetite  will  soon  fail,  and  digestion  become  painful  and  dis- 
turbed. When  given  to  fulfil  good  indications,  and  solely  to  relieve  the 
(lio-estive  functions,  their  effect  will  be  more  pronounced  and  beneficial. 
In  spite  of  the  assertions  of  some  authors,  their  stomachic  virtues  play 
but  a  feeble  part  when  they  are  required  to  aid  in  directly  restoring  the 
blood,  or  to  uphold  by  an  instant  support  the  vital  resistance  which  is  on 
the  point  of  sinking. 

The  distinction  between  tonics  and  excitants  is  now  clearer. 

Stimulants  give  more  energetic  play,  they  increase  and  expend  the 
forces  actually  (in  actu)  at  the  disposal  of  the  system.  Tonics  increase, 
raise,  repair  the  forces  which  the  system  may  use — the  radical  forces. 
The  former  have  a  very  manifest  and  constant  action  independent  of  mor- 
bid states,  because  the  system  may  always  hasten  the  expenditure  of  its 
acting  forces,  and  exhaust  the  vital  movement;  but  it  is  impossible  for  a 
man  to  increase  the  sum  of  his  vital  forces  when  they  have  all  the  physi- 
ological power  which  his  constitution  admits  of.  The  more  vigorous  and 
healthy  a  constitution  is,  the  more  will  stimulants  act  on  it;  the  more  food 
for  excitement  will  it  be  able  to  furnish.  On  the  contrary,  the  more  vig- 
orous and  healthy  an  organism,  the  less  capable  of  an  increase  of  radical 
force  through  the  action  of  tonics,  which  are  only  able  to  repair  where 
loss  exists. 

The  promptitude,  vivacity,  and  briefness  of  the  stimulant  action, 
compared  with  the  insensible  slowness,  the  silence  and  permanence 
of  the  tonic,  are  an  obvious  consequence  of  what  we  said  at  the  be- 
ginning of  this  section  upon  the  obscure  tonic  movements  of  the  tissues, 
the  radical  forces  of  the  system,  and  the  vital  resistance  of  the  nervous 
system. 

The  physiological  stimulants  of  the  acting  forces  are  constantly  pro- 
ducing a  loss  of  radical  force,  which  has  to  be  repaired  by  the  physiologi- 
cal tonics.  These  stimulants  consist  of  motion,  exercise;  the  waking 
state,  and  all  the  locomotive,  intellectual  and  affective  acts  which  fill  it; 
the  physiological  tonics  are  food,  sleep,  rest  of  the  organs,  and  that  con- 
servation, of  which  Barthez  speaks,  of  the  balance  of  activity  among  the 
functions,  which  habit  has  established  in  the  form  of  health  which  is  pe- 
culiar to  each  individual. 

But  in  extra-physiological  states,  in  certain  diseases,  the  reactions  of 
the  acting  forces  sometimes  require  to  be  called  out,  or  sustained,  while 


38  THERAPEUTICS. 

physiological  stimulants  are  no  longei  suitable.  Therapeutical  stimuli 
are  then  in  order.     We  shall  speak  of  them  in  another  place. 

In  other  morbid  states,  the  radical  forces  require  to  be  fixed  or 
brought  back  to  their  normal  energy  or  resistance,  and  the  use  of  physi- 
ological tonics  is  unsuited  to  the  circumstances.  Then  it  is  that  thera- 
peutical tonics  are  of  use. 

Having  now  studied  abstractly  each  of  the  forces  which  combine  for 
nutrition,  we  ought  to  add  that  these  three  are  solidary,  inseparable,  and 
in  realit-y  cannot  act  nor  be  modified  independently  of  one  another.  They 
do  not  rationally  exist  except  in  concurrence.  One  of  them  supposes  the 
other  two,  represents  them  in  its  way,  and  necessarily  includes  something 
of  them.  This  is  why  every  hygienic  or  therapeutic  modifier  acts,  not 
solely  on  the  specially  correspondent  force,  but  on  all  three  forces.  It 
acts,  however,  on  the  others  only  indirectly  and  by  means  of  the  force 
with  which  it  is  most  directly  related.  It  follows  that  when  we  say  that 
iron  acts  on  the  vascular  system  as  a  direct  inciter  of  ha3matosis,  cinchona 
on  the  nervous  matter  of  organic  life  as  a  radical  fortifier,  rhatany  on 
the  framework  of  tissues  as  a  primitive  tonic  and  roborant,  we  do  not 
exclude  the  indirect  actions  which  these  remedies  may  have,  the  one  on 
the  nervous  matter  and  the  organic  framework,  the  second  on  the  frame- 
work and  hffimatosis,  the  third  on  the  latter  and  on  the  nervous  tissue. 
Just  as  these  three  elements  mutually  interpenetrate,  to  form  an  indivisi- 
ble unity  of  organism,  so  the  three  tonic  properties  are  intimately  com- 
bined in  each  of  the  three  grovips  of  remedies;  only,  each  group  bears 
the  name  of  its  leading  quality.  Iron  has  distinct  astringent  and 
neurosthenic  properties,  but  the  former  are  less  marked  than  those  of 
alum  or  rhatany,  and  the  latter  less  certain  than  those  of  cinchona. 
Catechu  is  an  astringent,  and  a  stomachic  or  neurosthenic  of  the 
stomach.  And  cinchona,  quassia,  etc.,  are  plainly  roborants  or  tonics  to 
the  tissues. 

It  is  understood  that  these  generic  analogies  permit  each  species  of 
the  genus,  each  individual  of  the  species,  to  possess  its  own  individuality. 

Thus,  in  spite  of  their  analogies,  iron  and  cinchona  are  mutually  dis- 
tinct.    Both  are  tonics,  each  in  its  own  way. 


Analeptic  oe  Reconstituent  Toxics. 

This  first  category  includes  only  iron,  and  perhaps  manganese,  accord- 
ing to  the  recent  studies  of  M.  Petrequin  of  Lyons.  Certain  substances, 
as  fibrin  of  dark  meat,  broths,  raw  flesh,  maltine,  pepsine,  and  proteine, 
might  be  added,  as  containing  a  great  amount  of  analeptic  principle  in  a 
small  bulk,  and  as  being  the  most  restorative  of  all  alimentary  substan- 
ces. For  these  properties  they  are  often  prescribed  as  remedies,  not  only 
to  nourish  and  repair  the  body,  but  to  combat  a  certain  order  of  morbid 
phenomena.     They  are  thus  the  most  potent  succedanea   and  the   best 


RECONSTITUENT    REJIEDIES.  39 

adjuvants  of  the  action  of  iron,  the  only  analeptic  tonic  in  the  materia 
inedica. 

The  blood  must  be  impoverished  in  order  to  derive  benefit  from  iron. 
Many  and  various  are  the  diseases  which  give  rise  to  this  state.  In  our 
time  they  are  often  not  recognized  unless  they  are  so  well  marked  that 
it  would  be  impossible  to  mistake  them.  But  these  are  not  the  only 
cases  in  which  a  multitude  of  functional  lesions  spring  from  lack  of 
energy  and  proportion  among  the  assimilative  functions,  and  in  which 
the  leading  indication  is  to  increase  their  activity  by  analeptic  tonics. 
We  shall  here  discuss  some  points  of  physiology  and  pathology  which  are 
necessary  in  order  to  appreciate  the  indications  for  these  remedies. 

There  is,  perhaps,  in  physiology,  general  pathology,  practical  medi- 
cine, no  greater  and  more  fruitful  fact  than  one  which  is  found  in  several 
places  in  Hippocrates,  to  which  the  great  man  returns  with  a  satisfaction 
which  shows  how  wide  a  place  he  assigned  to  it.  What  breadth  in  the 
simple  word^,  Saxguis  moderator  nervorum  !  How  directly  does  it 
bear  its  fruits,  when  Hippocrates  deduces  that  inference,  so  true  and  so 
broad,  that  it  is  hard  to  say  which  of  the  two,  the  inference  or  the  former 
observation,  is  the  principle,  and  which  the  application — Febris  spasmos 
SOLVIT.  It  is  the  same  law  interpreting  other  facts,  when  he  states  that 
the  blood  is  a  soporific,  "sanguis  somniferus;  "  that  it  gives  wisdom  (i.  e., 
harmony,  connection,  solidity  of  intellect  and  morals),  especially  when  it 
has  its  normal  density,  "  sanguis  ad  sapientiam  facit  pr^esertim  quum  suani 
habet  consuetam  concretionem;  "  that  on  the  contrary,  when  too  liquid,  it 
produces  unreason,  "  sanguis  ad  insaniam  facit  quum  sit  nimis  dissolutus," 
etc. 

These  capital  propositions  govern  a  whole  class  of  affections  of  the 
nerves,  as  we  shall  see. 

Is  not  this  something  most  worthy  of  the  meditation  of  physiologists 
and  the  attention  of  practitioners,  this  perpetual  antagonism  between  blood 
and  nerves,  between  the  predominance  of  the  assimilative  and  that  of  the 
nervous  phenomena;  giving  rise  to  the  fact  that,  the  more  development 
and  activity  the  sanguineous  system  and  the  plastic  force  possess,  the 
more  fixed,  silent,  regular,  co-ordinate  are  the  nervous  acts;  that,  con- 
versely, the  more  poor  and  feeble  are  the  nutritive  and  vegetative  functions, 
the  more  blood  is  diminished  in  quantity  and  despoiled  of  its  organizable 
parts,  the  more  mobile,  exalted,  irregular,  are  also  the  nervous  forces  ? 
The  silence  of  the  nervous  phenomena  shows  no  weakness,  for  force  and 
power  arise  from  harmony.  Exaltation  and  mobility  are  anything  but 
tokens  of  force,  for  throughout  the  organism,  weakness  arises  from  dis- 
order and  want  of  harmony. 

The  simplest  observation  of  man  in  health  and  disease  affords  abun- 
dant attestation  of  the  truth  of  this  law,  laid  down  by  Hippocrates  for 
the  first  time,  and  one  might  say  for  the  last,  if  Sydenham  had  not  found 
the  facts  on  which  it  rests  in  nature,  rather  than  in  the  works  of  the  Father 
of  Medicine.     These  facts  were  his  torch  in  that  little  treatise  on  hysteri- 


40  THERAPEUTICS. 

Gal  disorders,  which  forms  part  of  his  letter  written  to  William  Cole 
(Sydenham:  "Op.  Med.,"  torn.  I.,  p.  2G6),  an  admirable  masterpiece  of 
observation  and  practical  medicine,  which,  in  spite  of  the  opinion  of  an 
excellent  writer  (Dubois  of  Amiens:  "Hist,  philos.  de  I'hypocond.  et  de 
I'hyster.,"  p.  370),  we  regard  as  constituting  one  of  the  best  titles  to  his 
glory.  We  are  proud  of  being  the  first  to  resume  these  ideas  since 
Hippocrates  and  Sydenham.  On  the  subject  of  antispasmodic  treat- 
ment, we  have  taken  them  as  our  guide  in  laying  down  the  radical  treat- 
ment of  essential  diseases  of  the  nerves,  of  which  the  antispasmodics 
were  but  palliatives.  It  is  time  to  give  currency  to  ideas  too  much  neg- 
lected, which,  we  venture  to  say,  form  the  secret  of  treating  many  spas- 
modic affections  and  neuroses. 

Ars,  imitatio  naturae. — Upon  this  principle  rests  Hippocratic  medi- 
cine. Our  task  should  be  to  learn  how  nature  departs  from  her  physio- 
logical state,  on  what  essential  conditions  this  state  depended  while  it 
was  maintained;  then,  by  what  paths,  by  the  aid  of  what  circumstances 
nature  returns  to  order  and  equilibrium.  If,  after  this,  we  find  that  in 
cases  where  nature  cannot  restore  herself,  art  or  therapeutics  can,  bv  imi- 
tation, do  that  which  the  organism  in  other  cases  can  do  of  itself,  we  shall 
have  shown  the  true  sources  of  the  curative  indication  in  an  important 
class  of  diseases. 

There  is  an  ancient  division  of  the  organic  functions  into  the  vital, 
comprising  respiration  and  circulation,  because  these  functions  are  vital 
])ar  excellence,  and  immediately  necessary  to  life;  and  the  natural,  com- 
prising digestion  with  its  adjuvant  acts,  and  generation,  because  nature 
has  placed  in  animals  invincible  instincts  which  lead  to  the  maintenance 
of  life  and  the  propagation  of  the  race.  There  is  a  nervous  system  which 
presides  over  these,  and  which  co-ordinates  their  functions  and  those  of 
animal  life.  We  stated  the  attributes  of  the  trisplanchnic  system  at  the 
beginning  of  this  section.  We  now  add  the  physiological  consequences 
of  these  attributes,  a  subject  to  be  resumed  under  Antispasmodic  Medi- 
cation. 

The  leading  characteristics  of  the  great  sympathetic  nerve  are:  1.  In- 
cessant continuity  of  action  ;  the  functions  of  life  are  directly  under  its 
keeping,  and  if  it  suspended  its  action  life  could  not  be  maintained  for  an 
instant.  2.  Complete  silence  in  action,  dumb  concentrated  activity  en- 
tirely without  the  cerebral  consciousness.  The  more  regular,  energetic 
and  salutary  this  action  is,  the  more  it  ought  to  be  remote  from  conscious- 
ness; this  is  the  stamp  of  robust  and  complete  health.  3.  Power  to  force 
and  subdue  the  will  invincibly,  to  control  the  locomotor  system  and  all  the 
apparatus  of  relation  by  making  the  brain  its  own  servant  or  agent;  a 
capital  fact,  forming  the  domain  of  instinct  and  the  passions.  4.  Nullity 
of  cerebral  influence  upon  the  phenomena  which  are  wholly  dependent 
on  the  action  of  this  system. 

Recall,  now,  that  whatever  leads  the  trisplanchnic  system  from  the 
performance  of  its  due  functions,  produces  what  is  called  nervous  disease — 


EECONSTITUENT    EEMEDIES.  41 

nervousness,  spasms.  We  shall  speak  further  of  these  under  Antispas- 
modic Medication. 

The  conditions  which  give  rise  to  the  nervous  state  may  be  classed 
under  two  general  heads:  1.  Causes  which  strike  the  ganglionic  system 
directly,  and,  so  to  speak,  snatch  from  it  its  natural  functions.  Among 
these,  in  the  first  place,  are  the  passions,  the  strong  affections  of  the  mind; 
next,  certain  morbific  principles  like  that  of  gout  or  rheumatism,  etc.  We 
have  nothing  to  do  with  this  class.  2.  Causes  which  affect  the  ganglionic 
system  indirectly,  removing  it  from  its  duties  by  removing  the  object  of 
its  activity,  to  wit,  the  food  or  the  blood.  The  visceral  innervation,  hav- 
ing then  no  object,  unable  to  use  its  activity  in  a  normal  and  regular  way, 
excites  a  thousand  disturbances  consisting  of  morbid  sensations,  vicious 
and  disorderly  movements.  This  class  is  more  powerful  and  more  fruit- 
ful; we  shall  dwell  on  it,  as  furnishing  the  most  important  indications  for 
analeptic  tonics. 

We  will  give  some  familiar  examples  to  show  how  the  nervous  condi- 
tion is  developed  as  assimilation  is  weakened:  first,  by  sudden  abstraction 
en  tnasse/  second,  by  slow  and  gradual  abstraction. 

Anoemia. — Observe  a  woman  surprised  by  an  abundant  and  fatal  haemor- 
rhage. In  a  few  moments  the  heart  will  beat  more  quickly;  soon  irregu- 
larly. This  is  a  commencement  of  spasm.  Anxiety  at  the  epigastrium, 
nausea,  fainting,  soon  appear.  The  stomach  throws  oft*  all  its  contents. 
A  gaseous  secretion  distends  the  intestines,  their  vermicular  movement  is 
exaggerated,  they  move  in  various  directions.  The  least  emotion  agitates, 
produces  unbounded  effects.  The  slightest  impression  produces  lively  emo- 
tion. Tears  flow  without  motive.  Respiration  is  thoracic  and  frequent,  or 
slow  and  sighing,  often  interrupted  by  deep  yawns.  The  eyes  soon  roll 
up,  a  sensation  of  strangulation  is  felt,  the  neck  and  arms  are  twisted,  the 
trunk  stretches  itself  convulsively,  the  legs  are  flexed,  and  an  hysterical 
or  epileptiform  attack  occurs.  If  the  bleeding  keeps  on,  the  above  symp- 
toms increase  in  intensity,  the  convulsive  attacks  become  more  frequent, 
and  often  at  a  moment  when  the  loss  of  a  few  drops  more  will  produce 
certain  death,  the  convulsions  are  at  their  height;  their  energy  is  fright- 
ful; then  comes  a  general  and  sudden  check,  the  icy  calm  of  which  is  in- 
terrupted only  by  a  few  twitchings.  The  jaws  set,  the  face  grimaces;  then, 
after  one  last  deep  breath,  the  woman  expires. 

To  the  observer,  this  joicture  affords  a  profound  lesson  in  therapeutics. 

But  the  warm  and  palpitating  corpse  contains  other  lessons. — If  you 
cut  an  animal's  throat,  and  remove  the  heart  and  entrails  suddenly,  the 
heart  beats  outside  of  the  chest,  the  entrails  contract — beat  both  in  vacuo 
and  without  reason,  if  we  may  so  say.  These  phenomena  constitute  spasm, 
taken  in  the  act,  unveiled  in  all  its  truth;  for  we  cannot  better  describe 
and  define  spasms  and  neuroses  than  by  saying  that  they  are  useless  sen- 
sations and  movements,  without  aim  or  destination. 

It  is  evident  from  these  first  examples  that  the  rapid  removal  of  blood 
causes  in  the  nervous  system  of  organic  life  an  unusual,  irregular  action, 


42  THERAPEUTICS. 

illegitimate  and  aimless  movements,  and  thus  becomes  the  most  efficient 
cause  of  maladies  of  the  nerves,  neuroses. 

If  the  relation  of  cause  and  effect  w^ere  always  as  plain  and  striking  as 
in  the  case  just  delineated,  every  one  would  be  convinced.  But  when  the 
cause  is  not  before  our  eyes,  in  material  and  irrefutable  form,  when  the 
only  effects  appear  under  forms  more  or  less  insidious  and  simulating  dis- 
eases of  another  sort,  then  it  is  harder  to  assign  them  to  a  common  and 
genuine  cause;  then  occur  the  worst  therapeutic  blunders,  especially  since 
the  reign  of  physiological  medicine  and  of  the  school  of  anatomical  path- 
ology. 

But,  though  less  evident,  the  physiological  cause  is  not  essentially  dif- 
ferent, and  the  therapeutic  indications  also  remain  the  same,  in  the  absence 
of  specific  agents  able  to  destroy  the  morbid  principle  directly. 

To  prove  this,  let  us  now  take  cases  of  less  marked  features;  let  us 
observe  these  features  in  still  more  obscure  cases,  where  induction  and 
analogy  must  be  invoked;  and  lastly,  in  cases  where  the  only  touch- 
stone is  found  in  the  effects  of  tentative  treatment,  as  if  to  give  a  striking 
application  of  the  Hippocratic  axiom  :  "  Morborum  naturam  curationes 
ostendunt,"  By  thus  passing  from  simple  to  complex,  from  the  incon- 
testable to  the  less  apparent,  and  observing  the  impossibility  of  draw- 
ing a  line  of  separation,  we  shall  succeed  in  throwing  light  and  bringing 
persuasion. 

Nothing  is  more  common  than  for  women  whose  menses  are  excessive 
in  quantity,  or  return  several  times  a  month,  to  be  tormented  with  vapors 
and  nervous  troubles.  The  digestion  is  soon  affected;  the  nutritive  func- 
tions disturbed;  the  crasis  of  the  blood  is  weakened,  and  menorrhagia 
increased;  and  from  this  indefinite  aggravation  of  cause  by  effect  results 
a  dilapidation  and  a  disorder,  a  functional  perversion  and  a  radical  debil- 
ity, from  which  it  is  hard  to  disentangle  the  true  indications  for  treatment. 
What  adds  to  the  doubt  and  confusion  is  that  some  secondary  symptoms 
are  almost  always  so  prominent  as  to  attract  the  chief  part  of  the  atten- 
tion, and  forhi  the  basis  of  diagnosis.  The  stomach  and  its  functions 
very  often  furnish  such.  The  gastralgia  and  constipation  are  here  only 
symptomatic  of  antemia. 

The  nervous  condition  of  women,  due  to  habitual  haemorrhages,  is  no 
more  to  our  present  purpose  than  that  due  to  other  similar  causes.  We 
give  it,  however,  the  first  place,  both  for  its  importance  and  for  the  influ- 
ence its  solution  ought  to  have  upon  practice. 

When  the  system  is  suddenly  deprived  of  a  large  quantity  of  blood, 
the  animal  functions  are  the  first  to  suffer.  The  brq,in,  the  senses,  the 
locomotor  system,  are  the  first  to  announce  the  insurrection  of  the  ner- 
vous system.  Then,  if  the  subject  survives,  and  blood  is  not  soon  re- 
stored in  quantity  and  quality,  various  functional  lesions  of  the  abdominal 
and  thoracic  viscera  soon  appear.  But  if  the  assimilative  faculty  has 
been  slowly  despoiled  of  its  material,  as  in  the  case  of  menorrhagia,  and 
particularly   if  the   despoiling  has  been  a  slow  process,  by  untimely  and 


RECONSTITUENT    KEMEDIES.  43 

prolonged  dieting,  chlorosis,  cachexia  from  intermittent  fevers,  or  other 
conditions  of  which  we  will  speak  below,  the  first  functional  troubles  are 
in  the  stomach  and  heart. 

If  in  this  case  the  latter  organs  give  the  first  sign  of  the  spasmodic 
condition,  need  we  be  surprised  '?  Have  we  not  pointed  out,  as  a  charac- 
teristic of  trisplanchnic  innervation,  the  necessity  of  continual  action; 
and  in  that  state  of  perfect  equilibrium  which  constitutes  health,  have  we 
not  noted  the  silence,  the  obscurity,  the  latent  action  of  these  forces,  and 
the  absolute  ignorance  in  which  the  brain  ought  to  rest  in  respect  to 
these  vital  operations  ?  The  nervous  action  which  regulates  these  oper- 
ations cannot  cease  without  putting  an  end  to  life;  hence  it  goes  on,  in 
spite  of  the  insuflficiency  of  the  reparatory  material  which  it  has  to  work 
upon.  But  as  soon  as  it  ceases  to  be  absorbed  and  regulated  by  the 
operations  preparatory  to  nutrition,  it  gives  rise  to  all  sorts  of  pathologi- 
cal phenomena,  which,  perceived  by  the  sensory  centre,  constitute  those 
abnormal  (that  is,  useless  and  objectless)  sensations  and  motions  which 
are  called  spasms  and  neuroses. 

The  stomach,  or  rather  the  solar  plexus — the  sensorium  commune  of 
the  vital  sense,  as  Grimaud  elegantly  conceives — is  the  focus  whence  the 
greatest  number  of  spasms,  pains,  functional  troubles  arise.  This  centre 
is  to  the  vital  and  natural  functions  that  which  the  brain  is  to  those  of 
relation.  Its  office,  so  to  speak,  is  to  sum  up  and  express  the  discomfort 
and  suffering  of  the  other  viscera.  Thus,  it  gives  rise  to  the  normal  sen- 
sation of  hunger,  and  transmits  to  the  brain  the  sense  of  this  essential 
need — a  need  not  confined  to  one  organ,  but  which  only  one  has  the  priv- 
ilege of  stating.  This  viscus,  then,  whose  acts  ought  always  to  be  un- 
known to  the  ego,  is  the  first  to  experience  erethism  when  the  system  is 
suffering  a  famine  of  reparative  material.  The  word  erethism  needs  a 
definition ;  it  is  employed  by  most  people  to  express  irritation,  orgasm, 
excitement,  excess  of  action,  force,  etc. 

Erethism  is  the  morbid  susceptibility  of  an  organ  due  to  privation  or 
insufficiency  of  these  physiological  or  natural  stimuli.  It  is  the  most  cer- 
tain sign  of  weakness.  The  physiological  stimulus  of  the  stomach  is 
food;  that  of  the  whole  system,  and  the  circulation  of  the  heart  in  par- 
ticular, is  the  blood. 

An  unsuitable  diet  puts  the  stomach  in  a  condition  of  erethism.  If 
you  add  anremia,  the  whole  economy  shares  in  the  erethism.  The  epi- 
gastric centre  also,  as  the  sensorium  commune  of  the  vital  sense,  will  feel 
and  reflect  the  general  suffering,  and  there  is  no  sort  of  abnormal  and 
painful  sensation*  of  which  it  may  not  be  the  seat.  If,  as  is  usual,  the 
chief  symptoms  are  pain  in  the  epigastrium  increased  by  pressure,  weight, 
cramps,  and  discomfort  of  the  stomach  after  eating;  still  more  if  there 
are  also  palpitations,  headache,  oppression;  still  more,  if  heat,  burning 
irritation,  is  felt,  with  eructations  of  gas  and  food,  etc.,  you  may  be  sure 
that  the  Avord  gastritis  will  be  uttered;  the  words  leeches,  diet,  mucilage, 
milk  diet,  chicken  broth,  etc.,  will  follow,  as  the  sliadow  follows  the  body. 


44  THERAPEUTICS. 

And  what  then  ?  The  unhappy  woman  (it  is  almost  always  a  woman), 
relieved  for  a  moment,  is  soon  plagued  with  general  troubles  and  local 
irritation  worse  than  the  former;  even  milk  begins  to  disagree,  because 
it  is  a  law  of  erethism  that  the  greater  is  the  loss  of  normal  stimulus,  the 
more  does  the  weakness  and  the  susceptibility  increase;  the  slightest 
pressure  on  the  epigastrium  may  produce  convulsions,  tears,  or  loss  of 
consciousness.  All  this  will  confirm  the  diagnosis;  the  gastritis  is  thought 
to  be  making  progress  in  spite  of  the  antiphlogistic  treatment;  a  new 
indication  is  thought  to  be  found  in  this  circumstance  for  renewed  ac- 
tivity of  treatment — and  so  on  for  years,  as  we,  unhappily,  have  too  often 
seen. 

A  gastritis,  sufficiently  intense  to  produce  the  pain  and  other  symp- 
toms of  the  erethism  or  the  neurosis  we  are  describing,  would  not  last 
many  days  without  disorganizing  the  mucous  coat  of  the  stomach,  pro- 
ducing peritonitis,  etc.;  but  the  state  we  are  describing  has  no  influence 
of  itself  upon  nutrition,  and  is  never  dangerous  to  life  of  itself. 

On  the  other  hand,  we  have  for  a  very  long  time  been  seeking  in  the 
hospitals  and  elsewhere  for  spontaneous,  acute,  frank  gastritis;  but  up 
to  this  time  we  have  reached  no  other  result  but  this,  that  the  disease  is, 
for  us,  a  chimera,  a  creature  of  fancy.  We  have  observed  acute  gastritis 
produced  by  the  contact  or  ingestion  of  poisonous  substances,  acids,  con- 
centrated alkalies,  alcohol,  etc.,  and  that  which  follows  indigestion  or  a 
too  stimulant  meal,  and  is  cured  by  two  or  three  days  of  abstinence;  but 
we  repeat  it,  never,  except  under  the  preceding  conditions  of  causation, 
have  we  recognized  a  disease  consisting  solely  and  primitively  in  acute 
inflammation  of  the  gastric  mucous  membrane.  The  only  acute  gastritis 
observed,  except  in  poisoning  by  irritating  substances,  is  that  which 
might  be  called  gastritis  crapulosa  (gastritis  a  crapula  of  some  nosolo- 
gists),  to  which  scarcely  any  but  men  are  subject;  while  we  have  ob- 
served that  women  are  more  specially  liable  to  gastric  neuroses,  which 
are  so  commonly  taken  for  phlegmasise. 

We  need  not  pursue  the  differential  diagnosis. — But  we  will  add  that 
it  is  well  to  distrust  excessive  sensibility  under  pressure  in  the  epigas- 
trium. This  exquisite  sensibility  is  scarcely  a  property  of  pure  gastritis. 
When  closely  questioned,  women  will  admit  that  it  has  no  analogy  to  the 
pain  produced  by  pressing  an  inflamed  part.  It  is  rather  a  painful  anx- 
iety, a  spasm,  an  indefinable  malaise,  than  an  organic  pain  properly  so 
called.  The  pressure  causes  a  sense  of  oppression,  of  cardialgia,  of  col- 
lapse, quite  like  that  which  attacks  the  same  region  under  the  sudden  in- 
fluence of  a  painful  emotion,  a  surprise,  a  severe  fright,  etc. ;  and  further- 
more, there  is  another  affection  of  the  stomach  which  is  observed  inde- 
pendently of  this  state  of  erethism,  and  which  causes  horrible  epigastric 
pains,  namely,  gastralgia — which,  also,  is  not  a  gastritis.  Many  persons 
in  perfect  health  of  stomach  cannot  stand  the  lightest  pressure  on  the 
epigastrium  without  severe  pain. 

The  state  of  which  we  speak  very  rarely  causes  vomiting,  while  acute 


KECONSTITUENT    KEMEDIES.  45 

gastritis  is  always  accompanied  by  it. — It  has  been  repeatedly  stated  of 
late  by  sceptical  and  minute  observers,  on  the  faith  of  necropsies  and 
facts  which  seem  most  exact,  that  the  state  of  the  tongue  has  no  connec- 
tion with  that  of  the  stomach;  inflammation  of  this  organ  is  no  more 
indicated  than  that  of  any  other,  by  redness  and  dryness  of  the  tongue. 
This  notable  error  has  been  one  of  the  chief  causes  that  have  prevented 
physicians  from  giving  up  their  blindness.  In  the  cases  we  speak  of  the 
tongue  is  moist,  red,  large;  it  has  all  the  signs  of  health,  except  that,  in 
many  cases,  its  papilla?  are  excessively  developed.  Or  they  may  be  only 
salient,  and  grouped  towards  the  tip  of  the  tongue,  bright  red,  and  de- 
prived of  skin  as  it  were,  in  which  case  tliey  show,  if  not  a  proper  gas- 
tritis, at  least  a  shade  of  vascular  irritation  of  the  mucous  membrane  of 
the  stomach  added  to  its  nervous  irritation,  and  the  physician  should  al- 
ways keep  this  complication  in  mind.  Or  the  tongue  is  red,  not  lanceo- 
late, the  papillae  not  inflamed,  but  erected  and  pressed  together  like  the 
pile  of  woollen  velvet,  occupying  the  whole  surface  of  the  organ:  then 
the  affection  of  the  stomach  is  purely  nervous — gastralgia,  or  dyspepsia 
with  erethism  of  the  organ. 

The  sensation  of  heat,  burnings  irritation,  in  the  absence  of  other 
signs,  has  no  value  as  a  characteristic  of  gastritis.  When  the  innervation 
of  an  organ  is  deranged,  it  may  produce,  as  if  by  hallucination,  sensations 
which  .in  health  result  only  from  fixed  causes;  and  this,  in  the  absence  of 
of  any  material  cause,  any  added  stimulus,  any  organic  lesion.  The  skin 
itches  and  burns  without  any  visible  cause;  the  stomach  gives  the  sense 
of  hunger  and  satiety,  independently  of  want  of  food  or  repletion,  etc. 

Difficulty  of  digestion,  oppression,  eructation,  etc.,  are  of  no  signifi- 
cance in  respect  to  gastritis.  They  are  the  effect  of  any  condition  of  the 
stomach  which  interferes  with  its  functions.  Nobody  supposes  that  gas- 
tritis is  the  only  thing  which  can  interfere  with  digestion.  We  will  say 
the  same  of  the  palpitations  and  cephalalgia  which  accompany  the  act  of 
digestion,  and  do  not  belong  exclusively  to  gastritis. 

Our  diagnosis  must  be  based  chiefly  on  etiological  circumstances,  the 
general  condition,  the  effects  of  various  treatment,  etc. 

An  important  distinction  between  the  neuroses,  debilities,  erethism — 
of  the  stomach  or  any  other  organ,  or  the  whole  system — and  inflamma- 
tory diseases,  is  the  fact  that  in  the  latter,  function  and  act  are  blocked, 
the  vital  manifestations  abolished,  stupefied,  impotent;  while  in  the  for- 
mer, all  these  are  exalted,  exaggerated,  mobile,  aroused  on  the  slightest 
occasion;  in  a  word,  have  sensations  and  movements  of  which  a  merely 
inflamed  part  is  incapable. 

Thus  the  stomach,  in  the  state  of  erethism,  often  gives  a  sensation  of 
unappeasable  hunger.  A  like  sensation  is  never  felt  in  gastritis,  which 
is,  on  the  contrary,  accompanied  by  absolute  disgust  and  anorexia.  The 
latter  is  a  distinctive  sign  of  the  highest  importance. 

When  the  circulatory  organs,  and  the  heart  in  particular,  are  in  rela- 
tion with  blood  which  fails  to  excite  them  sufficiently  to  regulate  and  re- 


46  THERAPEUTICS. 

strain  their  movements,  the  erethism  of  the  system  is  straightway  an- 
nounced by  palpitations,  suffocation,  thoracic  spasms,  frequency  and  false 
energy  of  the  heart's  beat,  irregularities  of  temperature,  and  often  a  real 
erratic,  slow,  nervous  fever. 

The  reproductive  system  soon  gets  the  upper  hand,  and  the  most  in- 
credibly varied  hysterical  symptoms  torture  the  life  of  the  woman.  The 
nervous  system  of  animal  life  soon  shares  in  the  erethism,  which  then 
becomes  general;  and  the  most  simple,  the  least  fatiguing  intellectual 
impressions,  sensations  and  occupations  overtask  and  worry  the  brain  and 
the  senses. 

If,  after  showing  the  effects  of  slow  and  rapid  loss  of  blood  upon  the 
nervous  SN'stem,  we  should  examine  the  effects  of  withholding  the  aliment 
from  which  blood  is  formed,  or  inanition,  we  should  have  to  write  the 
entire  nosology  of  nervous  affections,  for  this  condition  allows  or  excites 
all  of  them. 

But  let  us  turn  to  chlorosis,  which  presents  the  pathological  type  of 
the  cause  and  the  effects  which  we  are  studying. 

Chlorosis. — In  this  disease,  usually  at  the  period  of  puberty,  without 
any  loss  of  blood,  any  insufficiency  of  food  in  quantity  or  quality,  or  any 
hygienic  circumstances  likely  to  injure  assimilation,  the  forces  which 
govern  this  process  languish,  the  principal  viscera  become  inert,  the 
blood  grows  poor,  loses  its  plasticity  and  redness  through  a  considerable 
diminution  of  the  globules.  Then  the  most  alarming  debility  and  ere- 
thism occupy  all  the  organs,  and  the  patient  often  presents  a  table  of 
contents  of  all  the  nervous  affections. 

What  alterant  force  has  been  able  to  reduce  the  blood  to  this  state, 
in  which  it  is  only  an  abundant  serum  bearing  a  few  flaccid,  pale  glob- 
ules, without  vital  affinity  ?  What  cause,  what  reversal,  have  thus 
stopped  the  movement  of  vital  composition  and  decomposition  ?  for  in 
chlorosis  these  are  suspended.  Abundance  of  blood  circulates  in  vain; 
it  fertilizes  nothing,  gives  nothing,,  removes  nothing.  The  vegetative 
acts  are  blocked.  Vital  chemistry  is  stricken  with  inertia.  There  re- 
main in  the  system  none  but  nervous  phenomena,  and  those  of  a  per- 
verted sort. 

The  question  is  not  one  of  pure  curiosity.  Its  solution  ought  to  liave 
a  great  influence  on  the  prophylaxis  of  chlorosis,  and  especially  on  the 
treatment  of  the  first  symptoms. 

An  apparatus  which  for  fifteen  years  has  given  no  sign  of  life,  be- 
cause up  to  that  time  it  had  been  of  no  use  to  the  existence  and  the 
physiological  role  of  woman,  suddenly  awakens,  and  becomes  the  centre 
of  new  functions  which  claim  an  amount  of  vitality  so  great  and  so  spe- 
cial in  its  nature,  that  it  seems  as  if  a  new  creature  had  been  added  to  the 
former  ("  uterus  animal  in  animali  "),  and  were  governing  it  so  as  to  charac- 
terize the  woman,  "making  her"  (to  use  Van  Helmont's  energetic  ex- 
pression) "  what  she  is."  Van  Hehnont  also  spoke  of  the  uterus  as  a 
stranger  in  the  economy,  dependent  on  the  latter  only  for  nutrition,  '•  pere- 


KECONSTITUENT   REMEDIES.  47 

grini  hospitis  instar,  a  corpore  non  nisi  animaliter  dependens;"  while  the 
woman  obeyed  its  rule,  "mero  regiminis  imperio,  totam  regit  mulierem;" 
and  it  led  the  woman  as  the  moon  raises  the  water  of  the  sea,  "perinde 
atque  luna  solo  adspectu  aquis  prasidet,  eo  quod  uteri  vita  atque  potestas 
toti  imperet  mulieri," 

In  some  women  this  empire  over  the  organs  is  established  easily, 
without  resistance,  strife,  or  trouble.  In  such,  the  period  has  been  long 
and  gradually  prepared  for;  puberty,  menstruation,  fecundity,  the  new 
being,  develop  unknown  to  them,  and  continue  to  bear  a  mild  sway. 
Such  are  seldom  chlorotic  or  hysterical  unless  subsequently  causes  arise 
which  determine  these  conditions.  In  others,  however,  the  period  of 
puberty  is  the  signal  for  the  most  violent  disturbances.  The  establish- 
ment of  the  uterine  functions  meets  with  the  greatest  obstacles.  It  is 
chiefly  then  that  this  system  rules  the  whole  organism;  for  vitality  de- 
serts the  other  apparatus.  The  digestive,  respiratory,  circulatory,  secre- 
tory systems  lose  a  great  part  of  their  nervous  influence,  to  the  advan- 
tage of  the  organs  of  generation;  and  while  in  non-chlorotic  young  girls 
this  first  momentary  concentration  of  the  whole  system  of  forces  upon 
the  uterus  is  soon  followed  by  a  radiant  superabundance  and  expansion 
of  general  life,  in  those  affected  with  chlorosis  the  comjDensation  is  not 
made,  and  the  womb,  the  centre  of  so  many  efforts,  languishes,  and  fails 
to  enter  upon  its  important  attributes;  it  does  not  give  back  the  influ- 
ence of  which  it  deprives  the  other  organs.  The  relation  between  the 
acts  of  assimilation  and  innervation  is  almost  destroyed,  and  these  two 
orders  of  functions  exhibit  only  disturbance,  imperfection,  and  impotence. 

Thus,  there  are  two  facts  to  consider  in  the  study  of  chlorosis  and  in 
the  interest  of  its  treatment,  although  in  general,  and  at  present  in  the 
school  of  Paris,  only  one  of  them  is  thought  of  importance.  It  is  taught 
that  chlorosis  consists  essentially  in  a  considerable  diminution  of  the 
globules  of  the  blood,  and  the  disproportionate  increase  of  the  serum; 
and  that  correct  treatment  ought  to  aim  at  restoring  the  physiological 
composition.  Here  is  but  half  of  the  truth;  for  it  is  said  that  chlorosis 
exists  only  when  hydrjemia  is  well  marked:  it  seems  that  the  disease  only 
begins  at  this  moment,  though  it  is  really  only  an  effect  which  might 
have  been  anticipated  at  any  rate. 

Here  it  is  important  to  enter  into  the  refutation  of  the  errors  of  the 
disciples  of  chemical  therapeutics,  in  respect  to  the  use  of  iron. 

Chlorosis  is  defined  by  one  of  its  effects,  the  diminution  of  blood- 
globules,  and  of  the  iron  which  is  one  of  their  normal  ingredients.  Not 
inquiring  how  the  iron  diminishes,  and  taking  this  fact  for  the  disease, 
they  do  not  ask  how  it  is  restored,  and  take  restoration  for  cure.  This 
is  the  more  prized,  as  iron  seems  to  contribute  to  the  coloring  matter  of 
the  blood;  and,  pallor  being  one  of  the  most  striking  symptoms  of  the 
disease,  the  improved  complexion  is  regarded  as  complete  evidence  of 
cure,  and  as  cure  itself.  But  where  are  the  life  and  the  organs  mean- 
while ? 


48  THEKAPEUTICS. 

The  specific  in  chlorosis  is  then  of  a  different  sort  from  mercury  and 
cinchona.  The  latter  are  destructive  specifics,  alterants;  iron  is  a  more 
generous  specific,  for  it  directly  reconstructs,  by  itself,  like  a  food.  It  is 
to  the  chlorotic  not  a  morbicide  specific,  but  a  hygienic  specific.  How- 
ever this  may  be,  it  has  the  distinctive  mark  of  specifics — that  of  acting 
by  itself  and  without  the  intervention  of  the  organism;  and  it  must  be 
acknowledged  that  the  existence  of  the  normal  iron  of  the  blood,  its  di- 
minution in  chlorosis,  its  reappearance  under  chalybeates,  gives  an  air  of 
probability  to  the  theory. 

The  iron,  then,  allies  itself  with  the  pre-existing  molecules  of  iron, 
and  this  alliance  ("  soldering  ")  is  all  the  process? 

It  is  forgotten  how,  in  many  cases,  a  chlorosis  which  has  resisted  enor- 
mous doses  of  iron  well  absorbed,  suddenly  yields  as  by  enchantment  to 
a  journey  or  an  agreeable  feeling,  which  has  not  introduced  one  atom 
of  pharmaceutic  iron  into  the  S3^stem.  Chlorosis  gets  well  without  iron 
just  as  it  does  with  it;  and  there  are  several  tonics  which  give  the  same 
result. 

Nevertheless,  if  iron  excites  regeneration  of  iron  in  the  blood  more 
than  any  other  medicine,  the  amount  existing  in  the  coloring  matter  of 
the  o-lobules  is  so  small  that  the  enormous  size  of  the  doses  and  the  exces- 
sive  prolongation  of  the  treatment  are  evidently  mere  accessories,  and 
may  cause  several  inconveniences  unless  restricted  within  scientific  limits. 
If,  in  order  to  cure  chlorosis,  we  require  only  to  replace  iron  by  iron  phys- 
ically, why  is  it  that  other  cachexije,  equally  marked  by  diminution  of 
blood-globules,  are  not  in  the  least  benefited,  but  rather  made  worse  by 
iron  ?  The  fact  has  been  neglected,  that  chlorosis  is  almost  the  only  kind 
of  morbid  ana?mia  of  which  iron  is  the  special  remedy.  The  chemists  say 
that  the  vitellus  of  a  hen's  egg  contains  all  that  is  needed  to  form  the 
chicken.  They  say  that  traced  of  iron  are  discovered.  But  they  do  not 
say  that  after  incubation,  at  the  moment  when  the  chicken  is  about  to 
break  the  shell,  before  it  can  have  borrowed  iron  from  the  outer  world, 
its  blood  contains  iron  in  much  larger  quantity  than  the  vitellus  could  have 
furnished.  We  prefer  to  think  that  the  analyses  have  been  poorly  made; 
otherwise,  rejecting  the  idea  of  spontaneous  formation  of  a  simple  body, 
we  should  have  to  conclude  that  the  egg  absorbs  iron  through  the  shell 
along  with  the  respiratory  elements  of  the  atmosphere,  or  else  that  iron 
is  not  a  simple  body. 

However  this  may  be,  iron  cannot  be  longer  regarded  as  a  specific. 
Chlorosis  is  developed  without  direct  removal  of  iron;  without  hjemor- 
rhage;  it  recovers  spontaneously,  without  the  administration  of  iron;  and 
when  it  recovers  during  its  use,  it  does  so  because  the  haematosic  powers 
of  the  vessels  have  been  stimulated  by  it  to  the  formation  of  blood-cor- 
puscles, as  the  stomach  and  the  lacteals  may  be  to  the  formation  of  a  richer 
chyle.  Iron  does  not  act  by  increasing  immediately  the  quantity  of  pre- 
existing molecules  of  iron,  but  by  stimulating  the  formation  of  new  iron- 
bearing  globules. 


RECONSTITUENT    REMEDIES.  49 

The  power  which  forms  blood  exists  previous  to  the  iron,  and  without 
it  iron  would  have  no  more  effect  than  in  a  glass.  We  do  not  deny  that 
there  is  a  special  connection  between  the  properties  of  iron  and  the 
hffimatosic  properties  of  the  circulatory  apparatus;  but  the  connection  is 
a  physiological  one.  Iron  certainly  excites  the  formation  of  the  red 
o-lobules  more  specially  than  that  of  the  lymph  or  bile,  as  aloes  has  a 
special  power  over  the  secretion  of  the  intestines  rather  than  that  of  the 
kidneys;  and  digitalis  acts  on  the  heart.  But  in  this  I  do  not  see  any- 
thing specific  as  regards  the  disease, — which  is  what  a  specific  claims. 

Iron  plavs  one  part  in  ha^matosis,  and  oxygen  another.  Its  normal  and 
constant  presence  in  the  globules  is  a  token  of  this  function.  It  supposes 
in  these  living  bodies,  and  in  the  vessels  where  they  are  formed,  certain 
ha?matosic  energies,  of  the  existence  of  which  this  metal  is  one  condi- 
tion. 

We  will  say  as  much  from  another  point  of  view  concerning  the  com- 
pounds of  soda  which  are  so  common  in  the  blood,  where  they  correspond 
as  special  chemical  stimulants  to  other  homologous  properties  of  a  supe- 
rior order.  They  are  not  the  efficient  cause  of  the  latter,  but  their  co-or- 
dinate excitant  cause.  They  may  be  regarded  as  a  sort  of  condiment,  always 
present,  always  necessary  for  the  regular  fulfilment  of  the  incessant  com- 
binations between  the  elements  of  the  blood,  or  between  it  and  the  differ- 
ent organic  tissues. 

The  sanguifacient  properties  of  iron  have  some  analogy  with  these. 

Iron  restores  the  blood  by  intussusception  or  generation,  not  by  mix- 
ture or  juxtaposition.  The  clinic  shows  daily  that  its  diminution  is  an 
effect,  not  a  cause  of  chlorosis,  and  that  its  reappearance  is  an  effect  and 
a  sign  of  cure,  not  a  cause.  If  one  fairly  grasps  this  fact,  the  question  is 
decided.  Yet  there  are  those  who  admit  it,  and  yet  persist  in  calling  iron 
a  specific  in  chlorosis;  which  gives  at  once  an  idea  of  the  strength  of  the 
specific  and  of  its  defenders.  If  the  diminution  of  iron  is  only  an  effect 
and  sign  of  chlorosis,  how  can  its  increase  be  a  cause  of  non-chlorosis  ? 

It  is  true  that  the  effect  increases  its  own  cause.  It  follows  that  every- 
thing which  can  act  against  this  effect  has  an  action  against  the  cause  it- 
self, however  indirect.  We  maintain  that  if  iron  were  the  specific  for  chlo- 
rosis, chlorosis  could  not  get  well  without  iron.  Therefore,  w^hen  chlorosis 
recovers — not  spontaneously,  but  during  the  use  of  iron,  and  the  globules 
and  their  contained  iron  are  regenerated  in  proportion  to  the  amount  used, 
the  mechanism  is  the  same  as  when  they  are  regenerated  spontaneously 
and  without  the  aid  of  iron.  Why  does  not  the  iron  of  the  food  suffice  ? 
Does  the  food  nourish  by  juxtaposition  ?  Must  it  not  be  assimilated,  trans- 
formed, impregnated  with  the  life  of  the  organism  and  made  akin  to  it? 
Could  it  produce  this  effect  of  itself,  although,  to  use  Borden's  expression, 
it  has  experience  of  life  in  general  ?  Is  it,  then,  iron  that  by  itself  gives 
to  the  young  girl  this  warmth,  this  fruitful  vascular  organism,  this  circu- 
lation of  life,  of  sensation  and  movement,  which  seem  to  raise  her  in  a  few 
days  from  the  reptilian  to  the  mammal  state,  and  revivify  all  the  appara- 
4 


50  THERAPEUTICS. 

tus,  in  the  order  in  which  the  organs  are  developed  in  the  embryo  and  their 
functions  in  the  animal  after  birth  ? 

What  have  we  been  explaining — the  properties  of  iron  or  those  of  the 
chlorotic  organism  ?  Neither  of  these;  but  a  true  generation,  occurrino- 
in  the  midst  of  a  perpetual  movement  of  blood  at  all  points  of  an  immense 
network,  everywhere  present,  as  the  matrix  of  htematosis  ought  to  be;  for 
the  function  is  universal  in  the  circulatory  apparatus,  and  in  every  vessel, 
and  at  all  points  of  every  vessel,  blood  is  forming,  or  one  act  of  its  forma- 
tion is  occurring.  Who  that  has  ever  watched,  as  a  physiologist,  this 
spectacle  of  chlorosis  in  process  of  cure,  can  deny  that  the  process  is  a 
true  organic  evolution  ? 

This  generation  is  what  we  have  described  in  the  cure  of  chlorosis. 
But,  though  as  general  and  as  manifold  as  ha?matosis,  it  still  differs  from 
that  which  is  constantly  going  on  under  the  influence  of  reparative  nutri- 
tion (so  happily  named  by  Bacon  elementary  generation,  "  motus  genera- 
tionis  simplex")  in  these  points:  the  elementary  act,  when  performed  by 
nutrition  (of  which  organic  substances  are  the  seed),  fully  transforms  the 
substance  of  the  body  and  is  one  with  the  vegetative  life;  while,  when  per- 
formed by  chalybeate  medication  (presenting  only  an  inorganic  stimulus 
to  the  blood),  it  has  no  effect  save  to  arouse  excitability  in  the  blood  and 
certain  forces  which  are  to  this  liquid  what  the  nervous  substance  is  to  the 
entire  system.  What  the  chlorotic  patient's  blood  wants  is  life  much  more 
than  quantity.  This  is  not  so  in  phthisis  and  the  cachexiae  of  organic  mal- 
adies. Anf^mia  acts  primarily  on  the  vegetative  life  of  the  blood.  Thus, 
iron,  when  not  injurious,  fulfils  in  it  only  secondary  indications. 

The  pretended  specific  action  of  iron  in  chlorosis,  then,  unfolds  to  us 
the  spirit  of  the  doctrine  we  are  stating.  Iron,  like  all  medicines,  acts 
only  indirectly.  The  immediate  and  real  action,  the  efficient  action,  is  per- 
formed by  the  vivified  remedy;  it  is  the  treatment,  or  (what  is  the  same 
thing)  the  organism  physiologically  impregnated  with  the  drug.  This  is 
what  should  be  aimed  at,  and  what  makes  a  cure,  provided  that  the  sys- 
tem consents  twice — once  as  in  health,  to  the  physiological  action,  and  once 
as  in  disease,  to  the  therapeutic  action.  Now,  that  which  deprives  iron 
of  all  title  as  a  specific  in  chlorosis  is,  that  as  soon  as  the  system  feels  the 
physiological  action  of  iron,  all  is  over;  the  curative  effect  is  obtained,  and 
the  system  does  not  assent,  as  in  a  state  of  sickness.  Why  this  exception  ? 
Because  frank  chlorosis,  exempt  from  all  pathological  association,  is  less 
a  real  disease  than  an  organic  imperfection  in  evolution.  The  older  nosol- 
ogists  included  it  among  debilities. 

The  genital  apparatus  has  a  powerful  and  quite  special  influence  upon 
the  digestion  and  haematosis  of  woman.  At  the  epoch  of  puberty,  if 
the  life  of  this  apparatus  remains  concentrated  in  itself,  and  does  not  ex- 
tend its  influence  over  the  functions  of  individual  preservation,  the  latter 
fall  into  a  state  of  peculiar  languor  and  inertia,  which  is  one  of  the  thou- 
sand aspects  of  hystericism.  The  digestion  is  impaired,  hsematosis  less- 
ened, the  heart  and  vessels   are  attacked  by  a  violent  erethism  and  are 


KECONSTITUENT    REMEDIES.  51 

agitated  spasmodically,  like  all  starved  organs;  the  functions  most  closely 
related  to  intelligence  and  will  are  a  bizarre  mixture  of  torpor  and 
irritability,  etc.,  etc.;  chlorosis  is  present.  Here  is  not  a  disease  in  the 
sense  usually  attached  by  nosologists  to  the  word;  no  decided  morbid 
vice,  parasitic  in  the  economy,  the  proof  of  which  is  that  the  healthiest 
woman  may  fall  into  such  a  state  after  a  haemorrhage  or  a  simple  weak- 
ness of  the  uterine  system  or  accidental  disturbance  of  menstruation.  It 
is  a  want  of  equilibrium  between  the  two  systems,  in  the  perfect  harmony 
between  which  consists  the  strength  and  the  health  of  woman. 

We  here  speak  of  free  chlorosis  in  those  girls,  generally  dark-com- 
plexioned ("  chlorosis  fortium  "),  who  do  not  suffer  a  loss  of  richness  of  out- 
line, nor  of  elasticity  of  tissue.  These  cases  form  the  triumph  of  iron, 
the  chlorosis  being  pure  and  free  from  all  association  with  a  diathesis 
such  as  the  tuberculous,  and  from  all  the  forms  of  combination  with  other 
morbid  elements.  In  these  cases  of  free  chlorosis,  as  soon  as  the  system  is 
medicated  with  iron,  the  cure  is  as  complete  as  it  can  be — for  the  two  are 
one.  The  harmony  between  the  two  lives  may  again  be  disturbed,  and 
chlorosis  relapse;  but  the  cure  may  also  persist,  and  not  very  rarely. 
The  condition  on  which  iron  acts  as  a  specific  in  chlorosis  is,  that  the 
latter  shall  be  pure,  frank — that  is,  as  unlike  as  possible  to  diseases  which 
liave  specifics.  Unless  the  iron  finds  these  fine  types,  its  action  is  uncer- 
tain, imperfect,  soon  exhausted,  causes  accidents  and  intolerance,  acts  as 
an  inert  body,  or  as  a  very  irritant  substance.  False  or  symptomatic 
chlorosis  is  then  a  real  disease,  or  is  associated  with  a  real  disease,  and  at 
once  ceases  to  possess  a  specific;  an  excellent  proof  that  it  never  possessed 
one,  and  that  in  the  most  brilliant  cases  iron  acts  only  the  part  of  a  hygi- 
enic condition.  It  is  a  kind  of  physiological  condiment  which  we  may 
suitably  offer  to  the  system  when  unable  to  assimilate  food,  or  to  feel  the 
stimulus  of  the  non-nutritive  elements  which  form  a  natural  seasoning  to 
the  food.  But  though  the  condiment  acts  differently  from  food,  it  does 
not  escape  the  general  laws  of  life. 

Just  as  the  food  which  is  not  assimilated  is  a  foreign  body  in  the  sys- 
tem, and  as  this  assimilation  is  nutrition  itself,  so  iron  (I  might  add  soda, 
:sulphur,  phosphorus,  relatively  to  other  functions),  a  non-alimentary 
:substance,  but  an  exciting  cause  of  sanguification,  is  an  injurious  substance 
in  the  body,  as  such  is  eliminated,  and  determines  in  it  a  factitious  dis- 
ease unless  the  system  possesses  certain  properties  which,  revivified  by 
iron,  constitute  medication  by  iron. 

This  distinction  is  of  the  highest  importance,  and  we  prove  it  by  the 
differejice  between  the  cure  of  chlorosis  and  that  of  a  simple  or  physio- 
logical ani\;mia  following  hajmorrhage.  In  curing  the  latter,  reparatory 
food,  meat  (containing  iron,  no  doubt)  suffice.  The  therapeutic  action 
is  mingled  with  the  physiological,  and  pharmaceutical  preparations  of 
iron  are  rarely  needed.  In  chlorosis  it  is  not  so;  the  preparations  are 
often  indispensable.  What  could  we  say  more  directly  against  its  speci- 
fic nature  ? 


52  THERAPEUTICS. 

We  have  shown  that  humoralism  and  chimiatria  always  take  effects 
for  causes.  Does  the  name  chlorosis  (xA-wpd?,  greenish  yellow)  restrict  the 
vision  of  observers,  preventing  them  from  recognizing  the  disease  before 
it  has  reduced  the  blood  of  girls  to  the  condition  of  that  of  cold-blooded 
animals '?  It  would  be  much  better  to  call  it,  as  Morton  did,  nervous 
phthisis,  a  term  full  of  pathological  meaning  and  therapeutic  indications. 
Chlorosis  is  at  its  height  when  it  is  visible  in  the  greenish  pallor  of  the 
skin  and  the  colorless  mucous  membrane.  This  external  condition  takes 
away  the  merit  of  diagnosis,  and  announces  that  the  physician  has  already 
lost  much  time. 

Chlorosis,  before  reaching  this  point,  is  long  preceded  by  suspension 
of  the  action  of  the  principal  viscera  and  the  alterant  forces;  they  are  as 
it  were  paralyzed,  plunged  in  a  torpor  like  that  of  hibernation,  but  with 
the  difference  that  an  infinity  of  nervous  disorder  appears  in  proportion 
as  the  phenomena  of  nutrition  lose  their  activity,  and  the  blood  its  or- 
ganizable  elements.  Further,  these  nervous  disorders  in  this  case  are  in- 
fluenced by  the  developing  condition  of  the  genital  organs — an  influence 
so  mighty  that  it  causes  and  characterizes,  by  itself,  the  chief  neuroses  of 
woman. 

We  may  divide  this  malady  into  three  epochs,  which  follow  one  an- 
other in  a  necessary  relation  of  cause  and  effect. 

First  epoch. — The  action  of  the  visceral  apparatus  becomes  slow, 
almost  null.  Assimilation  is  as  if  suspended.  The  heart  and  stomach 
shows  their  erethism  and  weakness  by  their  abnormal  sensations  and 
movements.  The  poverty  and  liquidity  of  the  blood  cannot  yet  be  accused 
of  producing  this  state  of  languor  and  of  nervous  accidents,  for  they  pre- 
cede ana?mia  and  produce  it.  This  first  period,  during  which  the  blood 
changes — or  rather  becomes  impoverished — may  last  very  long  before  the 
chlorosis  is  revealed  to  everybody  by  the  complexion. 

But  the  inertia  of  the  assimilative  forces,  the  erethism  and  tlie  per- 
version of  visceral  innervation  which  are  its  necessary  consequence,  are 
not  without  influence  on  the  composition  of  the  blood;  it  loses  its  vitality 
at  last,  is  insensibly  despoiled  of  its  organic  elements,  and  the  young  girl 
falls  into  the  "  green  sickness." 

Second  epoch,  or  confirmed  cldorosis. — In  general  the  disease  is  not 
recognized  previously.  The  hydraemia  which  results  from  the  preceding- 
period  becomes  in  turn  a  cause,  and  produces  upon  the  entire  system  the 
effects  of  slow  loss  or  impoverishment  of  blood.  This  indefinite  aggrava- 
tion of  cause  by  effect  sooner  or  later  brings  on  the  third  period,  unless 
the  uterine  functions  are  perfectly  re-established  and  give  to  the  vital 
faculties  their  normal  equilibrium  and  power. 

Third  epoch,  or  chlorotic  cachexia. — Excessive  erethism  of  the  circu- 
latory system  produces  a  remittent  or  continued  nervous  fever  which 
consumes  the  system,  and  then  we  may  say  that  the  organism  consists 
solely  of  a  horribly  exasperated  nervous  system.  Life  is  maintained  by 
a  series  of  impressions,  all  of  which  are  spasms  or  pains.     The   natural 


RECONSTITUENT    REMEDIES.  53 

hygienic  agents,  when  exercising  their  gentlest  effects,  provoke  incessant 
disorders  of  contractility  or  sensibility.  The  entire  existence  is  but  a 
sensation  of  suffering,  anxiety,  and  general  distress.  The  person,  or  its 
survivor,  a  useless  nervous  system,  may  be  extinguished  by  exhaustion 
or  by  colliquative  discharges  and  phlegmasias  of  the  principal  organs,  such 
as  those  seen  in  persons  who  starve  to  death  or  succumb  to  various  kinds 
of  nervous  hectic  fevers. 

We  have  now  a  remark  of  the  highest  importance  to  make. 

In  many  cases,  the  external  signs  of  the  second  stage  are  entirely 
wanting.  In  some  young  persons  pallor  never  exists;  chlorosis  exists 
only  to  the  eye  of  the  mind,  but  exists  nevertheless.  By  saying  that  in 
these  cases  chlorosis  is  seen  only  by  induction,  we  mean  only  that  the 
complexion  is  good,  and  may  lead  to  errors;  for  the  blood  of  the  menstrual 
discharge  (very  many  chlorotics  have  their  menses),  or  that  from  leech- 
bites  or  venesection,  has  all  the  marks  of  chlorotic  blood. 

The  illusions,  the  deplorable  mistakes,  the  false  treatment  which 
spring  from  ignorance  of  this  fact,  are  truly  incalculable. 

The  fact  of  an  undecided  or  retarded  puberty,  the  resemblance  of  the 
symptoms  to  those  of  confirmed  chlorosis,  the  patient's  melancholy,  de- 
praved tastes,  eccentricity  of  character,  especially  the  appearance  of  the 
menstrual  blood  or  that  obtained  by  a  slight  prick,  the  cardiac  bruit  de 
souffle,  the  dilatation  of  the  cardiac  cavities,  the  various  rhonchi,  bruits 
de  diable,  whistling  of  the  arteries,  etc.,  etc.,  may  furnish  material  for  a 
diagnosis  independently  of  the  chlorotic  tint. 

But  if  this  circumstance  can  give  rise  to  so  many  errors,  how  will  it 
be  with  women  whom  their  age,  the  regularity  of  their  uterine  functions, 
the  appearance  of  good  health,  seem  to  exclude  from  chlorosis,  and  who 
have  suffered  no  loss  of  blood  sufficient  to  weaken  the  organism  and  dis- 
turb the  nervous  system? 

It  is,  however,  very  certain  that  most  of  the  nervous  ills  of  adult 
women — the  form  of  hysteric  which  (under  Anti-spasmodic  Treatment) 
we  call  hysterical  vapors,  undecided,  non-convulsive  hysteria,  and  most 
of  the  spasms  whose  aura  begins  at  the  epigastric  and  cardiac  region — 
are  very  often  due  to  inactivity  of  assimilation,  to  poverty  of  the  blood, 
which  in  turn  are  due  to  interruption  of  the  normal  physiological  relations 
between  the  functions  of  reproduction  and  of  individual  preservation. 

Certain  developments  and  distinctions  are  here  indispensable. 

Sydenham,  with  admirable  reason  and  medical  sense,  says  that  chloro- 
sis is,  without  doubt,  a  kind  of  hysterical  affection.  "  Chlorosin  sive  fe- 
brim  albam  quam  quidem  speciem  esse  affectionis  hysterica?  nuUius  du- 
bito." 

It  would  be  neither  less  just  nor  less  practical  to  state  that  hysteria  is 
a  species  of  chlorosis. 

Under  Antispasmodic  Treatment  we  have  admitted  two  principal 
forms  of  hysteria,  or  of  nervous  malady  with  the  uterus  as  its  focus. 
One  is  characterized  by  convulsive  attacks.     In  modern  works,  in  exam- 


54  THERAPEUTICS. 

inations,  and  all  the  public  acts  preliminary  to  the  degree  of  doctor,  in 
the  clinics,  etc.,  this  is  almost  the  only  one  named.  The  chief  point  at- 
tended to  in  treating  of  it  is  to  make  the  differential  diagnosis  from  epi- 
lepsy. 

AVe  have  said,  following  Sydenham  and  our  own  observation,  that 
convulsive  hysteria  affects  principally  strong,  vigorous  women,  those  least 
subject  to  nervous  evils,  "  temperamento  ut  2:)lurimum  plus  quam  solet  san- 
guineo;  "  those  of  a  virile  habit,  "  habitu  corporis  ad  viragines  accedente." 
This  form  is  the  least  interesting  to  study  from  the  therapeutical  point  of 
view.  It  is  little  modified  by  the  most  potent  palliatives  of  spasmodic 
disorder.  Those  which  we  are  now  studjang  under  the  name  of  radical 
remedies  have  much  less  influence  in  these  cases;  they  may  even  do 
harm,  or  at  any  rate,  no  good.  The  true  treatment  for  this  convulsive 
hysteria  lies  in  active  and  continual  use  of  the  muscular  forces,  bodily 
toil,  and  varied  gymnastics,  in  the  fatigue  of  exercises  which  Avomen  in 
society  in  general  shun;  for  we  hardly  observe  it  in  country  women,  in 
those  whose  position  forces  them  to  do  men's  Avork,  and  who,  as  Syden- 
ham says,  lead  a  hard  and  toilsome  life:  "  qua?  laboribus  assueta?,  dure  vi- 
tam  tolerant." 

AVomen  of  this  class  are  mostly  protected  from  convulsive  hysteria 
and  vaporous  hysteria:  the  former,  because  the  spinal  innervation  is  in- 
cessantly flowing  out  for  physiological  acts,  and  the  resulting  fatigue  pre- 
vents convulsions  and  produces  sleep,  which  is  their  most  potent  solvent; 
the  latter,  because  the  bodily  exercise  produces  an  activity  and  fulness  in 
the  ves-etative  life,  in  digestion,  circulation,  li;i?matosis  and  assimilation, 
which  guarantee  stability  and  calm  of  the  nervous  system. 

This  leads  us  to  our  question,  and  to  the  development  of  Sydenham's 
proposition,  the  terms  of  which  we  reversed,  thus:  the  nervous  ills  of  wo- 
men, vaporous  hysteria,  are  a  species  of  chlorosis,  or,  to  speak  more  ex- 
actly, a  special  erethism  of  the  nervous  system,  produced  by  debility  and 
insufficiency  of  the  nutritive  operations,  which  have  become  impotent  to 
impart  tone  and  restraint  to  the  system. 

This  state,  produced  by  the  alterative  or  the  weakness  of  the  influence 
of  the  reproductives  on  the  digestive,  hsematogenic  and  circulatory  func- 
tions, develops  and  exists  in  two  ways,  which  nevertheless  do  not  give 
rise  to  different  pathological  results,  and  make  no  change  in  the  nature  of 
the  therapeutic  indications. 

In  consequence  of  natural  weakness  of  temperament,  constitutional  or 
accidental  poorness  of  blood,  atony  and  imperfection  of  nutrition,  the 
uterine  nervous  system  acquires  a  state  of  erethism  and  predominance 
soon  shared  by  the  general  nervous  system ;  or  else  this  predominance  is 
primitive,  begotten  by  direct  causes,  such  as  the  passions  and  that  which 
acts  directly  on  innervation.  In  the  latter  case  that  follows,  which  we 
noted  in  the  first  period  of  chlorosis,  namely:  that  the  other  organs  are 
deprived  of  their  vitality  in  various  degrees,  nervous  disorders  commence, 
assimilation  languishes,  and,  hiematosis  and  assimilation  becoming  imper- 


RECONSTITUENT    REMEDIES.  65 

feet,  the  woman  falls  into  a  state  of  doubtful,  imperfect  chlorosis,  suffi- 
cient to  prevent  the  nervous  system  from  recovering  its  stability  and  the 
strong'  calm  of  its  movements. 

Hence  appears  the  reason  why  women  subject  to  the  convulsive  and 
intermittent  form  of  hysteria  are  generally  robust,  often  of  vigorous  con- 
stitution, while  those  with  hysterical  spasms  and  nervous  troubles  have 
generally  a  weak  and  languishing  constitution  and  health.  In  the  for- 
mer, the  nutrition  cannot  be  injured  by  a  few  attacks  at  long  intervals, 
affecting  only  the  cerebro-spinal  axis  and  its  dependencies;  while  in  the 
others  the  nervous  state  is  almost  continuous,  affects  chiefly  the  trisplanch- 
nic  system,  which  it  distracts  from  its  natural  and  regular  action  by  a 
thousand  tricks,  and  thus  brings  on  hysterical  cachexia,  as  we  shall  state 
hereafter,  and  as  S\^denham  formally  enounced  in  a  long  passage  to  be 
seen  in  a  subsequent  volume. 

If  asked  why  hysteria  takes  the  convulsive  and  epileptiform  shape  in 
muscular  women  of  strong  constitutions,  while  in  feeble,  slender  women 
with  weak  locomotor  powers  it  takes  the  spasmodic,  vaporous  form,  with 
those  infinite  aberrations  of  sensibility  and  of  the  reaction  of  the  lower 
apparatus  which  constitute  the  nervous  state, — we  might  answer  that  the 
vigor  and  activity  of  the  muscles  of  relation  in  the  one  call  out  the  con- 
Avulsion,  so  to  say;  that  the  exuberance  of  innervation,  during  an  attack, 
is  naturally  exhausted  by  the  excess  of  action  in  the  most  powerful  ap- 
paratus; that  the  pathological  movements  follow  the  lead  of  physiologi- 
cal habit,  while  in  the  other  the  hysterical  phenomena,  finding  an  organ- 
ism too  delicate  and  feeble,  do  not  g-o  to  the  extent  (if  we  may  so  speak) 
of  reacting  on  the  nervous  centres  of  animal  life;  and  instead  of  being 
distinctly  affected  and  betraying  themselves,  as  in  all  stronger  organiza- 
tions, by  an  impetuous  development  of  external  movements,  they  affect 
the  whole  nervous  system  indefinitely  and  without  exhausting  their 
forces,  exciting  disturbance  which,  while  less  violent  and  rapid,  is  still 
more  injurious,  more  indefinite  in  extent,  and  more  desperate.  No  one 
has  better  expressed  than  Broussais  this  invariable  habit  of  nervous  af- 
fections to  last  indefinitely,  or  else  to  show  themselves  by  violent  crises 
of  movement — that  is,  convulsions. 

But,  besides  anaemia,  there  is  another  pathological  cause  for  these 
generalized  diseases  of  the  nerves,  irregular  hysterical  neuropathies  with- 
out convulsive  attacks,  affecting  under  a  thousand  forms  the  apparatus 
both  of  organic  and  vegetable  life.  We  think  this  cause  is  a  general  af- 
fection, or  diathesis,  which  rules  and  produces  at  once  the  ana?mia  and 
the  nervous  symptoms.  Neuroses,  like  phiegmasije,  are  very  often  only  the 
symptomatic  expression  of  one  of  those  general  morbid  dispositions  called 
diatheses,  which  display  themselves  under  all  sorts  of  borrowed  forms. 
When  hysteria  appears  under  these  anomalous  forms,  its  elements  iso- 
lated, and  in  irregular  combinations,  rather  than  grouped  in  the  order 
observed  in  the  free  attacks,  the  existence  of  some  deeper  and  more  gen- 
eral morbid  disposition  must   be  suspected.     If,  in  addition  to  hysteric 


56  THERAPEUTICS. 

symptoms,  we  observe  j^seudo-inflammatoiy  congestions,  rheumatoid  af- 
fections, fever  without  type,  a  little  redness  of  the  tongue,  pains  in 
the  limbs,  neuralgias,  anorexia,  some  more  or  less  superficial  catarrhal 
symptoms,  emaciation,  and  finally  antemia,  'we  have  to  believe  that 
these  symptoms  do  not  form  the  entire  disease;  and  we  find  that  the 
anaemia  often  does  not  yield  to  analeptic  tonics,  which  sometimes  even 
increase  the  nervous  symptoms.  In  this  case  the  nervous  complications 
are  not  to  be  attacked  through  the  anjemia,  for  they  are  not  a  conse- 
quence of  it.  A  more  general  cause  governs  both.  But  yet,  if  the  di- 
gestive tract  is  in  good  order,  and  the  lungs  free  from  tuberculous  ten- 
dencies, iron,  though  not  victorious  as  in  the  neurosis  of  pure  chlorosis, 
fills  useful  indications. 

Hysterical  spasms  are  not  always  produced  by  the  organic  aifections 
which  impair  nutrition  and  weaken  the  blood,  as  they  are  by  those  which 
are  destitute  of  this  causal  element.  It  seems  as  if  the  organic  lesion 
then  played  the  part  of  a  powerful  derivant  or  exutory,  which,  like  all  the 
operations  of  the  alterant  force,  checks  the  free  development  of  nervous 
symptoms.     This  remark  is  a  confirmation  of  our  general  principles. 

What  happens,  for  instance,  during  and  after  acute  diseases  treated 
by  repeated  evacuations,  and  a  long  absolute  diet  ?  While  the  influence 
of  grave  inflammations  (as  an  acute  fever)  exists,  the  nervous  condition 
holds  its  peace;  it  is  not  suspected.  But  let  the  inflammatory  lesions 
depart,  the  fever  burn  out,  convalescence  become  established,  and  if 
proper  food  is  too  long  withheld  we  shall  see  spasms  appear;  hysteria, 
perhaps  for  the  first  time  in  the  woman's  life,  may  display  its  whole  bud- 
get of  symptoms,  until  an  actual  alimentary  fever,  of  a  physiological  na- 
ture, replaces  the  erethism  by  force  and  puts  a  check  on  the  exasperated 
nervous  system. 

Hypochondria. 

Man  is  subject  neither  to  hysteria  nor  chlorosis,  though  not  exempt 
from  diseases  of  the  nerves  and  an;\?mia.  But  while  analeptic  tonics  may 
be  required  in  his  anaemia,  it  does  not  follow  that  his  nervous  diseases 
present  identical  indications,  as  may  be  the  case  in  the  chlorosis  and  the 
hysterical  nervous  ailments  of  women. 

This  difference  is  due  to  the  fact  that,  during  the  whole  period  of 
uterine  life,  woman's  neuroses  have  a  more  or  less  hysterical  character, 
and  that  hysteria  has  quite  close  relations  with  chlorosis. 

Man  has  no  nervous  affection  or  cachexia  which  may  not  exist  in  wo- 
man. But  there  are  certain  varieties  of  ani«mia  of  which  we  will  speak 
as  belonging  more  especially  to  man.  First,  there  is  the  anaemia  of  hy- 
pochondriacs, often  determined  by  neuroses  of  the  stomach,  gastro-ente- 
ralgia,  dyspepsia.  Paludal  anaemia  holds  an  important  place  in  the  ca- 
chexies of  man.  The  unwholesome  professions,  the  excesses  to  which  man 
is  more  exposed  than  woman,  have  their  species  of  aniemia:  such  are  the 


b 


KECOJSrSTITUENT    KEMEDIES.  57 

saturnine  and  mercurial  cachexia? — those  of  zinc-workers,  minei'S,  forge- 
men,  glass-blowers,  bakers,  etc.  There  are  diseases  of  the  spinal  cord 
often  associated  with  anjemia.  It  exists  in  certain  very  grave  general 
paralyses,  called  progressive,  which  seem  to  attack  the  whole  locomotor 
system  at  once,  and  to  originate  at  once  in  the  sensitive  and  motor  ter- 
minations of  the  nervous  system  and  in  its  centres.  The  latter  affection 
is  often  caused  primarily  by  a  rheumatic  or  gouty  diathesis,  in  debilitated 
persons,  or  those  enervated  by  physical  fatigue,  grief,  or  excesses.  It 
appears  that  the  system  is  unable  in  these  cases  to  individualize  the  dis- 
ease, and  to  localize  it  frankly  for  the  general  benefit. 

It  is  surprising  that,  since  the  recent  exact  and  minute  investigations 
into  rheumatism,  we  still  neglect  the  dangerous  power  possessed  by  that 
disease,  of  producing  a  spasmodic  and  secretory  irritation  in  the  appa- 
ratus of  circulation  and  ha^matosis,  indicated  by  morbid  movements  of 
the  heart  and  the  blood-vessels,  progressive  diminution  of  the  blood- 
globules,  and  increase  of  serum.  This  produces  a  serous  plethora  and  a 
sort  of  cachexia,  which  deserves  the  name  of  rheumatismal.  This  morbid 
state  is  quite  common  after  acute  inflammatory  or  articular  rheumatism. 
It  begins,  we  believe,  with  that  disease,  and  forms  thenceforward  one  of 
its  special  marks;  but  its  character  appears  most  clearly  towards  the  close, 
when  the  masking  inflammation  becomes  less  intense.  It  is  often  seen 
persisting  indefinitely  after  the  cessation  of  articular  inflammations,  and 
forming  a  cachexia  sui  generis.  A  chronic  endocarditis,  an  organic  le- 
sion of  the  orifices  and  valves  of  the  heart  with  consecutive  hypertrophy, 
in  certain  cases  accompanies  this  condition,  soon  rules  the  symptoms,  and 
impresses  on  them  a  character  of  extreme  gravity.  But  it  is  certain  that 
rheumatismal  cachexia  is  also  seen  alone  without  any  visible  relation  to  a 
proper  organic  lesion  of  the  heart. 

Of  the  great  number  of  sorts  of  aneemia  without  organic  lesion,  there 
is  none  in  which  iron  succeeds  so  well  as  in  chlorosis.  But  it  must  never 
be  neglected,  except  perhaps  in  dyspepsia  and  gastro-enteralgia,  in  which, 
with  few  exceptions,  it  is  more  harmful  than  useful.  In  paludal  anaemia 
it  is  useful,  but  secondarily.  "We  will  say  as  much  of  its  accessory  uses 
in  the  saturnine  and  mercurial  cachexias.  An  animal  regimen,  wine,  cin- 
chona, insolation,  stimulant  baths,  and  frictions — these  do  as  much  as, 
and  more  than,  the  martial  preparations. 

In  a  word,  iron  finds  much  wider  application  in  the  diseases  of  women 
than  of  men;  probably  because  chlorosis,  the  chief  triumph  of  iron,  is 
usually  an  element,  if  not  the  sole  constituent,  in  woman's  anaemia. 

The  nervous  system  of  the  digestive  apparatus  in  man  is  to  hypochon- 
dria properly  so  called  that  which  the  nervous  system  of  the  generative 
apparatus  in  woman  is  to  hysteria. 

The  visceral  focus  of  h\'pochondria  is  the  apparatus  of  individual  pres- 
ervation; that  of  hysteria,  the  organs  of  reproduction  of  the  species;  as 
to  symptoms,  those  of  hysteria  are  all  kinds  of  spasms  or  convulsive 
attacks.     The  former  seem  to  us  produced  by  a  diffusion  of  the  uterine 


58  THERAPEUTICS. 

aura,  more  or  less  j^artial  or  general,  to  parts  or  the  whole  of  the  trisplanch- 
nic  system;  the  latter,  by  its  extension  through  the  sacral  nerves  to  the 
spinal  marrow. 

Hypochondria  and  chlorosis,  though  different  in  origin,  are  alike  in 
many  symptoms,  such  as  the  gastro-intestinal  neuroses,  those  of  the 
arterial  system,  bizarre  anomalies  of  innervation,  etc.  But  in  each  the 
symptoms  have  modes,  co-ordination,  and  very  special  characters. 

To  restrict  ourselves  to  what  concerns  the  digestive  apparatus,  we 
will  remark  that  in  hypochondria,  these  neuroses,  considered  by  them- 
selves, consist  chiefly  of  dyspepsia,  anorexia,  epigastric  anxiety,  and  all 
the  functional  disturbances  which  belong  to  the  disease;  also  that,  in  re- 
lation to  the  economy,  they  are  associated  with  egoism,  exclusive  pre- 
occupation with  self,  a  profound,  active,  restless  and  devouring  sadness, 
and  finally  cachexia  and  emaciation. 

In  chlorosis,  on  the  contrary,  these  neuroses,  considered  by  them- 
selves, consist  chiefly,  independently  of  the  epigastralgia,  of  depraved 
appetite,  bulimia,  canine  hunger,  etc.;  while,  as  respects  the  rest  of  the 
system,  they  go  with  indifference,  apathy,  torpor  of  ideas  and  feelings, 
and  finally,  cachexia  without  emaciation. 

In  each  case  there  are  anremia,  arterial  bruits,  asthenia,  an  absence  of 
all  appreciable  phlegmasia.  Does  it  not  seem  as  if  the  same  treatment 
would  be  good  in  each  case?  Yet,  in  the  one,  iron  succeeds;  in  the 
other  it  always  fails,  and  often  does  harm. 

In  beginning  these  remarks  we  proposed  to  study  the  laws  of  analep- 
tic tonic  medication  by  three  separate  inquiries,  subordinate  the  one  to 
the  other.  We  have  now  made  the  first,  which  was  intended  to  answer 
the  question,  how  nature  generally,  in  producing  nervous  disease,  devi- 
ates from  the  physiological  condition.  We  shall  now  attempt  to  solve 
the  two  others  together,  on  account  of  their  mutual  dependence. 

We  wish  to  know  from  what  conditions  that  physiological  state  re- 
sults, and  by  what  circumstances  nature  is  aided  to  return  to  order  and 
equilibrium.  From  tliis  very  Hippocratic  study  we  shall  deduce  the  most 
solid  therapeutic  rules. 

We  have  said  with  Hippocrates,  and  it  cannot  be  too  often  said :  "  the 
blood  is  the  calmer  of  the  nerves."  Sydenham  fully  understood  and  fer- 
tilized this  truth.  He  made  it  the  leading  thought  in  his  precious  dis- 
sertation on  hysteria.  All  his  views  of  the  immediate  nature  of  this  dis- 
ease, all  the  fundamental  therapeutic  indications  which  his  vast  and  en- 
lightened experience  throws  out,  are  faithful  reproductions  of  it. 

This  great  physician  ("  Op.  Med.,"  t.  I.,  p.  264),  with  his  well-known  in- 
imitable expression  of  truth  and  candor,  relates  how,  being  called  to  a 
patient  whose  doctor  had  bled  and  purged  him  repeatedly  and  kept  him 
on  strict  diet,  on  account  of  the  violence  of  the  fever,  he  declared  that 
the  singular  nervous  symptoms  formed  no  part  of  the  previous  disease, 
but  were  solely  due  to  lack  of  food — convalescence  having  already  com- 
menced.    This  diagnosis  being  established,  the  treatment  was  self-evident; 


RECONSTITUENT    REMEDIES.  59 

"  ac  proinde,"  says  he  in  conclusion,  "  suadebam  ut  pullum  gallinaceum  as- 
sum  in  prandium  juberet  parari,  et  simul  vinum  modice  hauriret:  quo 
facto  et  carnibus  deinceips  moderate  vescens,  nunquam  deinceps  fletum 
hunc  convulsivum  passus  est." 

It  is  in  the  blood  that  the  animal  spirits  (to  use  Sydenham's  expres- 
sion) are  regenerated. 

When  the  blood  is  not  sufficiently  nutritious  to  feed  the  nervous  sys- 
tem with  the  elements  which  it  is  constantly  expending  in  all  the  acts  of 
life,  that  system  falls  into  a  state  of  erethism,  and  ceases  to  be  in  har- 
mony with  its  physiological  stimuli — which  embrace  all  the  external  and 
internal  agents  that  affect  man.  Hence  incalculable  disorders  of  inner- 
vation. No  impression  is  felt  as  it  ought  to  be;  no  movement  or  reaction 
takes  place  regularly,  beneficially.  No  act  of  sensation  or  motion  fulfils 
its  physiological  end.  Hence  spasms;  for  we  have  defined  these  patho- 
logical phenomena  as  involuntary  sensations  and  motions,  useless  and 
aimless.  "  Quum  enim  utrisque  (hystericis  et  hypocondriacis)  desit  ea 
spirituum  firmitas  qufe  in  robustioribus  atque  iis  quorum  facultates  jugi 
SPIRITUUM  VEGETOEUM  suBsiDio  ACTUAXTUE  Semper  invenitur,  impressiones 
rerum  minus  gratai'um  nequeunt  perferre,  sed  vel  ira  vel  dolore  subito 
perciti,  perinde  sunt  irritabiles,  etc." 

After  recounting  the  causes  which  determine  hysterical  diseases  of 
the  nerves,  Svdenham,  from  whom  we  borrow  these  phrases,  adds  in 
relation  to  their  immediate  causes:  "  Cujus  quidem  draftas,  origo  atque 
CAUSA  ANTECEDEXS  est  debilior  dictorum  spirituum  crasis,  sive  nativa 
ea  fuerit  sive  adventitia;  unde  quavis  Trpo^aaei  dissipatu  faciles  sunt,  et 
eorumdem  systema  nullo  fere  negotio  dirimitur."  And  among  the  most 
potent  incidental  (adventitia?)  causes  of  this  state  he  notes  the  absence 
of  food  and  loss  of  blood:  "  quum  e  diverso,  non  alia  causa  ita  constanter 
pariat  hujus  modi  affectus  ac  solent  dictas  evacuationes." 

In  the  whole  animal  economy,  the  vegetative  functions,  the  acts  of 
nutritive  composition  and  decomposition,  are  the  most  important  and  re- 
quire the  most  calm  and  repose;  and  nature  seems  to  point  to  this  when 
she  withdraws  these  acts  from  consciousness,  and  executes  them  in  a 
silence  and  obscurity  which  attest  the  fulness  and  regularity  of  their 
performance. 

It  has  always  been  known  that  this  interior,  hidden  or  vegetative  life 
absorbed  and  put  in  fetters  the  external  life — the  active,  mobile,  unstable 
and  exaggerated  manifestations  of  feeling  and  movement,  which  produce 
the  physiological  nervous  temperament.  Matter  rules  over  and  stifles 
the  mind;  digestion  kills  thought,  etc. ;  such  are  the  proverbial  expres- 
sions of  this  fact. 

In  pathological  states,  this  is  found  everywhere.  Nervous  symptoms 
are  never  fewer  than  when  a  fever  or  a  grave  inflammation  exists;  and 
these  two  phenomena,  the  most  general  in  pathology,  are  essentially  and 
specially  connected  with  the  functions  of  nutrition,  of  intimate  vegetable 
life.     If  then  a  sanguine  fever  supervenes  upon  primitive  nervous  symp- 


60  THERAPEUTICS. 

toms,  the  latter  are  quieted.  Similarly,  whatever  be  the  cause  of  a  fever, 
provided  it  act  directly  on  the  nervous  system  in  such  a  way  as  to  pro- 
duce an  essential  spasmodic  state,  as  soon  as  the  class  of  nervous  symp- 
toms wliich  we  are  studying  appears,  the  fever  ceases,  but  often  to  the  pa- 
tient's great  risk,  for  reasons  which  we  have  not  time  to  set  forth  here. 
The  observation  of  this  capital  fact  inspired  that  admirable  passage  in  the 
Coan  maxims:  "  Convulsiones  sanat  exorta  febris  acuta  qujE  prius  nou  fuit; 
quodsi  prius  fuerit,  exacerbat.  Quin  etiam  prodest  urinam  albumineam,  al- 
vum  ferri  et  somnos  inire;  "  and  this  other  aphorism:  "  febrem  convulsioni 
supervenire  melius  est  quam  convulsionem  febri."  In  fact,  healthy  fever 
and  inflammation  are  regular  phenomena,  like  circulation  and  nutrition — 
synergic  operations  which  have  an  aim,  bear  evidence  to  the  harmony  of 
the  forces,  and  which,  while  acting,  exclude  irregularity,  incoherence, 
want  of  salutary  tendency. 

No  one  has  failed  to  remark  the  curious  and  important  differences 
which  exist  between  the  nervous  system  of  a  person  in  a  long  fast  or 
under  severe  diet,  and  the  same  person  after  he  has  suitably  satisfied  his 
need  of  food. 

If  it  be  a  man,  we  will  say  in  brief,  that  he  will  present  the  most  of  the 
symptoms  of  proper  hypochondria.  If  a  woman,  we  shall  see  the  infinite 
variety  of  symptoms  which  belong  to  vaporous  hysteria;  then,  after  a  long 
alimentary  restoration,  as  soon  as  the  nervous  system  has  received  sulficient 
tone,  the  fixity  and  calm  of  action  will  be  seen  to  return.  The  sadness, 
cowardice,  anxiety,  misanthropy,  egoism  of  hypochondriacs  will  give  place 
to  the  gayety,  confidence,  general  bien-ttre,  vital  expansion,  philanthropy 
of  the  sanguine  man;  the  troubles,  the  nervous  mobility,  chokings,  palpi- 
tations, tears,  chills,  pains — hysteric  spasms,  in  a  word — will  be  replaced 
by  the  stability,  consistency,  force,  and  functional  harmony  of  the  stout 
country-woman. 

As  Sydenham  observes,  hypochondria  is  hysteria  in  a  man,  and  con- 
versely: "  Si  affectiones  hypochondriacas  vulgo  dictas  cum  mulierum  hys- 
tericarum  symptomatibus  conferamus,  vix  ovum  ovo  similius  quam  sunt 
utrobique  phienomena  deprehendemus   (loc.  cit.,  p.  256);  and  further  on 

(V.,  p.  250) eorum  alfectuum  quos  in  feminis  hystericos,  in  mari- 

bus  hypochondriacos  appellandos  censemus." 

If  Sydenham  had  not  gone  so  far  as  to  confound  and  identify  these  two 
diseases,  and  if  his  usual  reserve  had  not  perhaps  prevented  his  assigning 
them  to  different  nervous  localities  in  the  respective  sexes,  a  difference 
which  establishes  all  the  difference  in  etiology,  symptomatology  and  thera- 
peutics which  separates  them,  he  would'  have  left  little  to  say  upon  the 
nature  and  treatment  of  these  complaints,  especially  of  hysteria. 

The  condition  of  the  absence  of  these  ills  consists  in  a  natural  propor- 
tion between  the  nervous  and  the  sanguine  systems;  an  equilibrium  be- 
tween them,  dependent  on  the  primordial  constitution  of  each. 

If  this  equilibrium  be  disturbed  at  the  expense  of  nutrition,  "we  know 
the  nervous  troubles  which  follow.     If  it  be  at  the  expense  of  the  nervous 


RECONSTITUENT    REMEDIES.  61 

system,  its  functions  are  as  it  were  stifled,  stupefied,  stricken  with  tardi- 
ness, weakness,  and  true  narcotism.  A  fed  animal  sleeps.  A  man  of  great 
digestive,  assimilative,  and  ha?matogenic  powers,  who  indulges  his  coarse 
tastes  beyond  his  needs,  is  shamefully  like  an  animal.  He  is  heavy,  sleepy, 
without  vivacity  or  aptitude  for  action,  dull  in  sensibility,  thick,  slow,  and 
narrow  of  comprehension.  The  passions,  the  violent  sentiments  of  love 
and  hate,  have  little  eifect  upon  him.  His  nervous  system  is  always  asleep 
— Sanguis  somniferus. 

How  often  have  we  seen  the  insomnia  of  certain  convalescents,  reveries, 
even  delirium  itself  ("  delirium  inane,  vacuum  ")  yield  to  a  broth,  or  any  sort 
of  alimentary  tonic  !  The  desire  to  sleep,  often  insurmountable,  which 
almost  everybody  feels  after  eating,  is  a  plain  proof  of  the  calming  and 
even  stupefying  influence  of  the  blood  on  the  nervous  system. 

Sydenham  has  perfectly  comprehended  and  stated  this  need  of  equili- 
brium between  the  blood  and  the  nerves  in  order  to  prevent  neuroses. 
These  are  his  words:  "  Illud  enim  est  animadvertendum,  quod  non  nuda 
spirituum  debilitas  per  se  considerata,  sed  eorumdem  debilitas  ad  sanguinis 
statum  comparatorum  draftas  quam  patiuntur  causa  sit.  Fieri  enim  potest, 
ut  infantis  spiritus  satis  firmi  robustique  sint  pro  sanguinis  ratione,  qui 
tamen  debitam  ad  sanguinem  adulti  hominis  proportionem  non  teneat. 
Jam  vero,  quum  ex  jugi  lactis  usu  et  diasta;  quantumvis  ilia  sit  cruda  et 
invalida,  sanguis  mollior  et  tenerior  evadat,  si  spiritus  ab  eo  nati  sanguini 
pares  tantum  sint,  satis  bene  se  res  habet." 

Let  us  now  reply  to  the  third  and  last  part  of  the  problem;  and,  to  con- 
clude the  subject  of  analeptic  tonics,  inquire  whether  in  cases  where  nature 
cannot  restore  herself,  art  may  so  far  imitate  the  natural  operations  as  to 
do  what  nature  herself  very  often  can  do. 

Unhappily,  the  cases  where  art  is  needed  to  aid  nature  in  restoring  the 
balance  between  the  nervous  and  assimilative  systems  are  but  too  numer- 
ous. The  therapeutic  means  for  doing  this  are  the  analeptic  tonics,  which 
may  be  divided  into  two  classes.  The  first  contains  the  only  analeptic 
tonic  in  the  materia  medica,  iron,  and  perhaps  the  compounds  of  manga- 
nese. The  second  would  include  the  resources  of  hygiene,  and  may  be 
subdivided  into  direct  and  indirect  remedies,  the  former  including  very 
nutritive  ingesta  which  contain  much  in  small  volume;  the  latter,  the  acta, 
circumfusa,  and  applicata,  including  suitable  bodily  exercise  or  gymnastics, 
the  influence  of  air,  and  cool  baths. 

The  last  subdivision  does  not  meet  the  definition  we  gave  of  ana- 
leptic tonics,  for  its  remedies  do  not  return  directly  to  the  blood  its 
reparative  elements;  but  they  are  such  potent  auxiliaries,  they  so 
clearly  arrest  vegetative  life  and  regulate  the  organic  functions,  that 
they  cannot  be  overlooked.  Furthermore,  they  are  sometimes  called 
upon  to  fulfil  the  indications  of  tonic  analeptic  medicine,  as  we  shall  show 
directly. 

JIartial 2)reparatio>(S. — Sydenham  (1.  c),  having  stated  the  symptoms 
of  hysterical  affections,  aiid  given  his  opinion  as  to  their  remote  and  di- 


62  THERAPEUTICS. 

rect  causes,  passes  to  treatment,  of  which  he  lays  down  the  foundations 
in  these  words: 

"  Ex  omnibus  quje  nos  hactenus  congessimus  abunde  mihi  constare 
videtur  pr^ecipuam  in  hoc  morbo  indicationem  curativam  earn  esse,  qua^ 
sanguinis  (qui  spirituum  fons  et  origo  est)  corroborationem  indigitat;  quo 
facto  spiritus  invigorati  eum  servare  possint  tenorena  qui  et  totius  corpo- 
ris et  singularium  partium  oeconomiae  competit." 

What  agent  does  he  resort  to  to  fulfil  this  fundamental  indication  ? 
To  the  preparations  of  iron:  "  Ad  sanguinem  confortandum  et  proinde 
etiam  spiritus  ex  eo  prognatos,  remedium  aliquod  martiale  seu  chalybea- 
tum  ad  dies  triginta  pni^scribo  assumendum,  quod  aliud  non  certius  his 
votis  respondet. 

We  need  not  here  insist  further  on  the  importance  of  this  remedy  in 
chlorosis,  nervous  affections,  etc. 

It  is  hardly  possible  to  state  absolute  principles  in  regard  to  its  contra- 
indications. In  well  diagnosticated  chlorosis,  it  rarely  fails  entirely,  and 
is  much  more  rarely  harmful.  Intolerance  is  almost  always  transient, 
and  is  overcome  at  last;  and  this  is  to  be  done  by  making  a  judicious 
choice  of  forms,  and  especially  suitable  formulae,  by  skilful  management  of 
the  doses,  by  selecting  the  surfaces  which  tolerate  it  best,  by  interposing 
days  of  rest  in  the  treatment,  by  adding  correctives,  auxiliaries,  etc.,  etc. 

V\^e  must  be  much  on  our  guard  against  deceitful  contra-indications, 
suggested  a  priori  by  the  state  of  the  stomach  or  intestines. 

Broussais  says  ("Extr.  des  doctr.,"  t.  IV.,  p.  564):  "We  hear  much  of 
the  success  of  iron  in  chlorosis;  excellent,  like  any  other  tonic,  if  the 
stomach  is  languid  from  aniBmia;  very  bad,  if  the  menses  are  retained  by 
a  visceral  irritation.  We  must  always  judge  of  it  by  the  irritation,  i.  e., 
by  the  solids." 

How  can  a  man  of  the  experience  and  weight  of  Broussais  profess 
that  it  is  indifferent  what  tonic  we  give  in  chlorosis  ?  What  !  will  any 
tonic  we  please,  cinchona  or  iron,  gentian  or  iron,  oak  bark  or  iron,  Co- 
lombo or  iron,  equally  cure  chlorosis  ?  and  when  we  prescribe  iron  so 
universally,  is  it  only  from  routine,  tradition,  an  old  relic  of  alchemistic 
prejudice  which  orders  us  to  oppose  iron  to  chlorosis  because  iron  is 
strength,  hardness,  Mars,  and  chlorosis  is  debility,  softness,  feminine  en- 
ervation ? 

It  is  rather  because  the  exclusive  organicists  always  have  a  horror  of 
the  remedies  which  are  thought  to  act  directly  upon  the  liquids  before 
affecting  the  solids;  and  it  is  hard  to  deny  this  action  in  the  case  of 
chalybeates. 

In  summing  up  and  formulating  the  general  indications  for  iron,  it 
seems  to  us  just  and  practical  to  say  that  it  is  chiefiy  of  use  in  morbid 
states  which  are  essentially  characterized  by  inertia  and  profound  devia- 
tion of  the  assimilative  force,  with  impoverishment  of  the  blood  and  all 
the  consequent  symptoms;  when  these  conditions  are  not  sympathetic, 
have  come  to  pass  slowly,  and  have  so  perverted  the  digestive,  hcemato- 


KECONSTITUENT    REMEDIES.  63 

genie  and  vegetative  powers  that  these  functions  are  unable  to  elaborate 
the  food  as  is  required  for  nutrition,  and  the  principal  reconstituents  are 
carried  directly  into  the  secundte  viae. 

Recalling  what  is  said  above,  we  shall  see  that  this  conclusion  is  de- 
duced simply  from  the  observation  of  the  most  important  facts,  those 
most  characteristic  of  chlorosis. 

We  add  a  few  very  important  contra-indications  for  the  analeptic  ton- 
ics, and  for  iron  particularly. 

The  reaction  provoked  by  the  mistakes  and  exaggerations  of  physio- 
logical medicine  has  gone  too  far,  and  often  has  denied  everything  when 
distinctions  only  were  needed. 

We  have  said  that  gastritis,  as  it  has  been  described,  and  we  might 
venture  to  say,  invented  by  the  Val-de-Grace,  was  a  pathological  rarity, 
and  was  only  seen  in  cases  where  it  was  caused  by  irritant  agents  taken 
in  incendiary  aliments  and  in  acrid  poisons.  This  is  true,  except  in  a  few 
rare  cases  which  we  need  not  mention  here. 

But  does  it  follow  that  irritation  of  the  stomach,  subacute,  chronic  and 
obscure  in  most  cases,  is  an  invention  made  at  will,  which  must  give  place 
to  pure  and  physiological  gastralgia,  another  enormity  of  our  epoch  ? 

No!  these  shades  of  gastritis,  or,  more  properly  speaking,  of  gastric 
irritation,  are  an  excessively  common  disease,  though  happily  very  rare  in 
combination  with  chlorosis,  where  iron  is  so  useful. 

It  is  a  great  pity  that  they  most  frequently  exist  in  women  for  whom 
analeptic  tonics  seem  perfectly  suitable. 

In  the  most  of  such  cases,  we  find  one  of  the  following  general  condi- 
tions, joined  to  the  gastric  irritation  in  question. 

Sometimes  there  is  a  herpetic  diathesis,  proved  by  dartrous  derma- 
toses, previous  or  coexistent.  Whatever  the  languor  and  the  poverty  of 
the  nutritive  functions,  however  great  the  anaemia  and  cachexia,  iron 
almost  always  fails. 

In  other  cases  these  women  have  been  formerly  scrofulous.  The  clas- 
sic signs  of  this  vice  have  mostly  ceased;  they  are  no  longer  called  scrof- 
ulous, but  debilitated  and  lymphatic.  Their  periods  are  bad,  they  can 
digest  nothing.  Almost  all  have  subacute  or  chronic  gastritis,  which  the 
enemies  of  physiologism  exaggerate  to  dyspepsia  or  gastralgia,  without 
reflecting  th.at  acquired  and  simple  gastralgia  is  extremely  rare,  except  in 
chlorosis,  anjemia,  and  nervous  rheumatism. 

Before  puberty  and  menstruation,  gastritis  and  enteritis  are  very  com- 
mon in  scrofulous  young  women  or  strumous  and  lymphatic  little  girls. 
This  is  plain  from  the  state  of  their  tongues,  their  lips,  and  the  difficulty 
of  digestion.  The  anti-scrofulous  remedies,  all  excitants  and  tonics,  do 
them  decided  harm.  It  is  singular  how  iron  disagrees  with  the  scrofu- 
lous, or  succeeds  but  partially.  It  is  due  to  the  fact  that  in  the  scrofulous 
diseases,  which  differ  from  chlorosis  as  one  cachexia  does  from  another, 
as  one  species  of  aniemia  from  another,  irritation  (scrofulous)  is  always 
imminent,  and  is  very  easily  excited  by  iron;  as  Broussais  says,  they  are 


64  THERAPEUTICS. 

made  of  a  very  irritable  material,  because  their  diathesis  produces  many 
morbid  products,  the  formation  of  which  often  depends  upon  special  irrita- 
tions and  suppurations. 

These  patients  cannot  take  iron,  except  when  the  deposits  of  scrofu- 
lous matter  are  forming  in  them  by  the  laws  of  physiological  secretion 
without  irritation  or  scrofulous  phlegmasiae;  as  is  seen  in  certain  phthisi- 
cal patients  whose  lungs  are  stuffed  with  tubercles  without  any  pulmo- 
nary phlegmasije. 

A  large  number  of  morbid  nervous  symptoms  annoy  women  who  seem 
most  suited  for  treatment  by  analeptic  tonics  and  iron;  yet  these  persons 
cannot  bear  it — it  even  does  them  harm.  In  these  cases  there  is  almost 
always  some  diathesis  which  makes  them  irritable,  and  complicates  their 
amemia  with  a  morbid  principle  which  iron  cannot  conquer  or  neutralize. 
Gout,  rheumatism,  those  various  diatheses  which  the  class  of  dartres  imper- 
fectly includes,  are  the  most  frequent  obstacles  to  the  success  of  ferrugi- 
nous treatment.  A  cause  which  very  often  interferes  with  success,  in  spite 
of  apparent  reason  for  their  use,  is  amenorrhoea  in  non-chlorotic  women. 
In  this  case  the  stomach  is  almost  always  irritated;  organic  injury  is  al- 
ways imminent  or  existent;  iron  fatigues  quickly,  fails  at  once,  or  is  appar- 
ently of  no  use. 

In  all  these  cases  the  insufficiency  or  harmfulness  of  iron  is  natural 
and  easy  to  explain.  Iron  is  an  analeptic  and  not  an  alterative.  There 
is  a  cachexy  in  these  persons,  but  of  a  very  special  kind — rather  the  effect 
of  a  diathesis  which  is  incessantly  fruitful  of  irritation  than  a  simple  de- 
fect of  proportion  among  the  constituents  of  the  blood.  The  blood  is 
poor,  but  it  is  vitiated  by  a  morbific  principle,  and  the  chalybeates  are 
suitable  only  for  repairing  a  simple  insufficiency,  uncomplicated  by  any 
diathesis. 

As  to  the  chlorosis,  we  should  not  expect  always  to  cure  it,  perma- 
nently and  perfectly,  with  iron.  By  iron  you  give  the  blood  plasticity 
and  coloring  material ;  the  patient  regains  color  and  strength.  The  treat- 
ment is  suspended,  and  in  a  few  months  all  the  symptoms  of  chlorosis  ap- 
pear in  order.  The  blood  is  artificially  enriched,  but  the  woman  is  unable 
to  maintain  the  richness  without  aid.  Marriage  takes  place,  and  sterility, 
dyspepsia,  menorrhagia,  leucorrhcea,  low  spirits,  palpitations,  backache, 
constipation,  sick  headache,  etc.,  show  a  weak  constitution  and  a  life  for- 
ever embittered  by  suffering  and  by  unfitness  to  fulfil  the  duties  of  mater- 
nity. If  a  woman  in  this  state  of  predisposition  to  chlorosis,  often  irre- 
mediable, has  a  child,  affections  of  the  womb,  as  ulceration  of  the  neck, 
prolapse,  metrorrhagia,  dyspepsia,  infiltration,  dry  cough,  general  dilapi- 
dation, emaciation,  nervous  fevers,  various  neuralgias,  etc.,  too  often  re- 
duce the  poor  wretch  to  an  unendurable  and  cruel  state  of  ill -health,  which 
at  the  turn  of  life  sometimes  ends  in  fatal  organic  diseases,  more  fre- 
quently in  a  premature  and  cacochymic  old  age,  and  most  rarely  by  a 
metasyncrisis  and  a  salutary  revolution. 

It  is  not  enough  then  to  put  the  ear  to  the  carotids  and  prescribe  iron. 


I 


EECONSTITUENT    REMEDIES.  65 

Yet  such  is  to-day  the  sum  of  the  diagnosis  and  treatment  of  this  affec- 
tion. And  those  empirics — the  professors  of  exact  medicine  who  do  no 
more  than  that — proclaim  themselves  as  the  representatives  of  progress  ! 

In  the  cases  just  mentioned,  iron  does  act,  but  inadequately;  and  a 
cure  must  depend  on  the  combination  of  other  remedies. 

Substcmtial  diet. —  Gymnastics. —  Cool  baths. — These  agents  are  po- 
tent adjuvants  of  the  iron  treatment  in  chlorosis  and  hysterical  nervous 
disorders.  We  must  now  show  in  a  few  words  the  reasons  which  some- 
times induce  us  to  use  them  exclusively. 

Iron,  as  above  stated,  is  most  proper  in  diseases  where  the  blood  has 
lost  its  excitant  and  plastic  qualities  slowly  and  by  a  gradual  perversion 
of  the  visceral  functions;  also  whenever  the  preparatory  acts  of  vital 
chemistry  are  not  performed,  and  cease  to  react  advantageously  upon  the 
food  so  as  to  form  assimilable  principles,  as  is  seen  in  chlorosis. 

The  alimentary  tonics  are  good  when  the  assimilative  functions  and 
the  blood  have  suffered  inertia  and  poverty  for  a  short  time,  as  after  and 
during  convalescence  from  acute  febrile  diseases  which  have  imposed  an 
active  and  rapid  labor  upon  the  alterant  forces,  or  a  long  and  trying 
period  of  coction,  especially  in  children  and  vigorous  adults. 

Strict  diet  must  be  observed,  while  the  alterant  forces  have  to  per- 
form a  necessary  pathological  task.  To  introduce  food  would  then  be 
asking  of  these  forces  an  excess  of  nutritive  action,  which  would  check 
either  the  pathological  or  else  the  reparative  elaboration.  Hippocrates 
has  said  as  much  in  his  aphorisms  (the  10th  of  section  2):  "Impura  cor- 
pora quo  magis  nutriveris,  eo  magis  Ifedes." 

The  morbid  alterant  process  once  at  an  end,  restriction  does  harm;  it 
causes  debility  and  nervous  troubles,  which  do  not  occur  while  the  vital 
chemical  forces  are  employed  in  digesting  and  concocting  pathological 
products. 

In  humoral  diseases,  diet  is  much  more  needful  than  in  nervous;  and 
a  proof  that  the  acts  of  the  alterant  forces  are  exclusive  of  the  nervous 
phenomena,  aberrations  of  sensibility  and  motility,  in  short,  spasms,  is 
found  in  the  fact  that  in  the  acute  humoral  or  febrile  diseases  where  these 
pepsic  forces  (to  use  the  expression  of  Hippocrates)  are  very  active,  there 
are  no  spasms,  disorders  of  the  nerves,  and  that  if  they  appear,  it  is  a 
sign  of  the  suspension  of  the  pathological  labor  and  of  irregularity  in  the 
course  of  the  disease. 

The  food  given  in  convalescence  from  acute  disease  seemed  a  very 
important  matter  to  Hippocrates,  who  gave  much  attention  to  it  in  a 
special  treatise  ("  De  vie,  trat.  in  acut."),  and  in  several  aphorisms  of  the 
first  section. 

Towards  the  decline  of  acute  fevers,  severe  inflammations,  exanthema- 
tous  pyrexiae,  great  sagacity  is  required  to  decide  when  to  begin  to  give 
food.  New  symptoms  then  often  occur,  fever  persists  or  appears,  etc., 
which  opportune  feeding  immediately  puts  an  end  to. 

Galen  knew  that  after  certain  fevers  or  intense  acute  diseases  which 
5 


QQ  THERAPEUTICS. 

had  much  weakened  the  patient,  a  nervous  fever  arose  vphich  was  calmed 
by  analeptic  tonics.  "  Equidem  ita  febricitantes  aliquos  ostendi  tibi 
maxime  ex  iis  qui  e  longo  morbo  convaluerant,  quorum  quum  uni  forte 
fortuna  occurrissem  qui  mox  ante  horrescere  coepisset,  ut  rem  exposuisset, 
dato  ex  vino  diluto  pane,  continuo  horrorem  inhibui;  atque  ut  semel  dicam, 
quibus  incipientis  adhuc  accessionis  aderant  symptomata,  iis  omnibus 
panem  ex  vino  diluto  esculente  mature  exhibens,  horrorem  statim  in- 
hibui et  febrem  prohibui." 

The  presumed  duration  of  the  disease,  the  losses  the  patient  has  suf- 
fered, which  have  reduced  him,  so  to  speak,  to  the  outlines  of  his  figure, 
liis  habits,  the  form  of  the  disease,  whether  remittent,  intermittent,  or 
continuous,  must  in  general  form  a  guide  to  prescribing  the  diet.  The 
following  aphorism  of  Hippocrates  will  sum  up  a  part  of  these  motives: 
"  Considerare  oportit  etiam  jegrotantem,  num  ad  morbi  vigorem  victu 
sufficiet,  et  an  prius  ille  deficiet,  et  victu  non  sufficiet,  an  morbus  prius 
deficiet  et  obtundetur." 

Without  enumerating  all  the  cases  where  alimentary  tonics  are  re- 
quired, it  will  suffice  to  say  generally  that  they  are  called  for  whenever 
the  assimilative  force  and  the  blood  liave  been  rapidly  enfeebled  by  abun- 
dant losses,  or  by  diseases  during  which  the  acts  of  vital  chemistry  have 
been  occupied  with  a  pathological  labor  which  demanded  a  protracted 
strict  diet;  and  that  they  are  powerful  to  arrest  all  the  symptoms  arising 
from  these  conditions,  when  the  digestive  and  lia?matogenic  functions 
retain  their  physiological  power. 

The  effect  of  food  in  chronic  diseases  belongs  to  the  subject  of  re- 
gimen and  hygiene,  and  we  need  not  speak  of  it  at  length.  It  is  obvious 
that  in  these  affections,  as  soon  as  the  functions  begin  to  be  regular  and 
normal  in  their  mutual  action,  the  alimentary  tonics  acquire  considerable 
curative  power,  especially  when  aided  by  gymnastics,  etc.,  of  which  we 
will  now  say  a  few  words. 

"The  exercise  of  the  locomotor  muscles,"  says  Broussais  (Proposit. 
373,  "  Ex.  des  doctr.,"  t.  I.),  "  is  the  best  means  of  destroying  convulsive 
mobility.  It  displaces  the  visceral  irritations  (the  vicious  latitude  which 
Broussais  gives  to  the  word  irritation  allows  us  to  take  it  as  meaning 
here  pains,  spasms — in  a  word,  neuropathy)  by  consuming  a  superfluous 
activity,  and  by  calling  the  forces  towards  nutrition  and  the  exhalant 
and  secretory  tissues." 

This  proposition  contains  a  profound  truth,  too  much  overlooked  or 
despised  by  physicians  who  would  suppose  their  cure  a  bad  one,  and 
themselves  unworthy  of  their  title,  if  they  had  cured  without  the  aid  of 
pharmacy;  a  truth  equally  despised  by  patients,  in  whose  opinion  the 
physician  sinks,  when  he  has  conscience  enough  not  to  rack  them  with 
his  drugs,  and  who  think  that  their  ills  are  slighted,  or  that  a  cure  is 
despaired  of,  when  hygiene  forms  the  only  means  of  cure. 

It  is  a  proverbial  saying  that  mental  labor  is  more  fatiguing  and 
exhausts  the  economy   much  more  than  that  of    the  body;    but  we  do 


EECON^TITUENT   REMEDIES.  67 

not  give  a  physiological  reason  for  this  seemingly  extraordinary  differ- 
ence. 

Does  the  man  of  the  closet,  the  meditative  writer,  living  from  morn- 
ing to  evening  in  the  immobility  and  silence  of  study,  expend  more  vi- 
tality than  he  whose  labor  demands  continual  bodily  movement  and  mus- 
cular activity  in  the  field  ?  No;  but  if  the  latter  expends  much,  he  re- 
pairs much,  while  the  former  expends  without  repairing. 

Too  continual  and  intense  exercise  of  thought  keeps  the  man  of  let- 
ters in  a  continual  nervous  state.  The  vital  movements,  instead  of  being 
expansive,  fruitful,  imparting  activity  to  the  organic  processes  of  vegeta- 
ble life,  such  as  digestion,  circulation,  h^ematosis,  secretion,  etc.,  are  com- 
pressed, chained,  and  the  assimilative  force  languishes;  hence  the  fre- 
quency of  nervous  diseases  in  this  class  of  men.  Their  labor,  instead  of 
increasing  the  functional  activity  of  the  nutritive  organs,  is  an  incessant 
cause  of  languor  and  perversion  of  these  organs,  and  soon  the  cause  is 
increased  by  its  effect.  Imperfect  digestion,  whence  want  of  appetite; 
no  desire  for  alimentary  repair;  difficulty  of  secretion,  exhalation,  dis- 
charge; inertia  of  the  respiratory  functions;  deficiency  of  muscular  fa- 
tigue; indigestions;  excessive  cerebral  activity;  and,  as  a  result  of  all 
combined,  loss  of  sleep,  that  beneficent  tonic. 

Thus,  without  fatiguing  himself,  without  making  a  legitimate  expen- 
diture of  life  which  might  cause  a  need  for  salutary  repair,  these  persons 
forbid  their  system  the  satisfaction  of  its  most  important  demands,  by 
weakening  and  diverting  the  acts  which  preside  over  the  fulfilment  of  its 
wants. 

The  contrary  is  the  case  with  those  who  do  bodily  labor  in  the  open 
air.  They  expend  an  enormous  amount  of  vitality,  in  return  for  which 
they  get  a  keen  and  genuine  appetite  which  they  satisfy  to  purpose  and 
for  legitimate  needs.  Their  haematosis  is  powerful,  their  circulation 
active;  the  secretions  and  exhalations  abundant  and  of  good  quality; 
their  sleep  profound,  natural  and  restorative. 

In  such  persons  the  acting  forces  (to  use  Barthez'  expression),  in  con- 
stant and  well  proportioned  exercise,  far  from  being  exhausted,  simply  in- 
crease the  sum  of  radical  forces,  in  which  they  constantly  find  new  power 
of  action.  We  have  seen  that  the  nature  of  analeptic  tonics  is  to  invig- 
orate the  radical  forces  of  the  system.  "  The  energy  of  the  radical  forces 
increases  in  a  ratio  compounded  of  the  intensity  of  the  action  of  the  forces 
acting  in  each  function,  and  the  constancy  of  the  mutual  relations  habitu- 
ally existing  among  all  the  functions 

"  The  repeated  agitation  of  the  entire  body  in  suitable  exercise,  and 
the  repeated  impressions  of  fresh  air,  excite  the  radical  forces  of  the  vital 
principle."  (Barthez:  "  Nouveaux  Elements  de  la  science  de  I'homme,"  t. 
II.,  p.  168.) 

There  are  women,  subject  to  disorders  of  the  nerves,  in  whom  neither 
iron  nor  alimentary  tonics  can  recall  the  nervous  functions  to  order;  they 
are  chiefly  such  as  are  subject  to  convulsive  hysteria,  with  some  who  are 


68  THERAPEUTICS. 

plagued  with  spasmodic  and  vaporous  hysteria.  The  only  useful  tonics 
for  these  are  bodily  exercise,  kept  up  with  great  perseverance,  and  well 
directed  gymnastics. 

There  are  other  women  of  vigorous  and  sanguine  constitution,  subject 
to  all  the  h3'sterical  spasms  and  the  nervous  ills  chiefly  attributed  to  deli- 
cate and  puny  women.  For  these,  the  only  therapeutic  indication  is  to 
consume  by  muscular  exercise  their  superfluous  activity,  and  to  direct  their 
forces  to  nutrition  and  to  the  exhalant  and  secretory  tissues,  as  Broussais 
has  it. 

The  species  of  tonics  which  we  are  now  speaking  of  is  perhaps  the  only 
one  suitable  for  hypochondriacs,  who  hardly  ever  can  support  the  tonics 
of  the  materia  medica  on  account  of  the  excessive  irritability  of  their  gas- 
tro-hepatic  system,  which  sometimes  becomes  a  degree  of  irritation  and 
chronic  subinflammation,  especially  when  the  malady  is  old.  We  know 
what  confidence  Sydenham  placed  in  horseback  exercise  in  these  diseases: 
"/Et  vero  nihil  ex  omnibus  quse  mihi  hactenus  innotuere,  adeo  impense 
SAXGUiXEM  SPiRiTUSQUE  FOVET  FiRMATQUE  ac  diu  multumquc  singuUs  fere 
diebus  equo  vehi.  Quid  quod  sanguis  perpetuo  hoc  motu  indesiuenter 
agitatus  exagitatus  ac  permistus  quasi  renovatur  ac  vigescit." 

The  same  end,  again,  reached  by  diiferent  means.  It  is  still  analeptic 
tonic  treatment,  with  the  immediate  object  of  restoring  the  nutritive  forces. 

But  much  method  and  attention  are  required  in  order  to  give  these 
tonics  in  suitable  form  and  dose.  Not  only  ought  muscular  exercise  not 
to  exceed  the  limits  of  the  individual  strength,  but  it  is  indispensable  that 
they  be  regulated  with  respect  to  the  sort  of  affection  for  which  they  are 
used.  They  ought  to  occupy  and  call  into  activity  all  the  functions  of  re- 
lation and  to  be  in  harmony  with  an  intellectual  or  moral  aim;  to  be  pro- 
portioned to  the  sleep  and  food,  and  seconded  by  suitable  temperature 
and  clothing:  great  persistency  must  be  used,  and  no  discouragement  felt 
because  no  benefit  is  felt  at  the  outset,  since  all  hygienic  remedies  have  a 
progressive,  gentle,  slow,  insensible,  but  yet  durable  and  profound  influ- 
ence. 

"  The  increase  of  radical  force  which  is  produced  indirectly  by  an  exer- 
cise of  the  functions  conformable  to  health,  demands  our  chief  attention. 
It  is  always  in  a  ratio  compounded  of  the  intensity  of  the  action  displayed 
by  the  acting  forces  in  each  one  of  the  principal  functions,  and  of  the 
maintenance  of  the  mutual  relations  of  activity  among  these  functions 
which  habit  has  established  in  the  form  of  health  which  belongs  to  each 
person. 

"The  radical  forces  thus  reproduced  (by  bodily  exercise)  offer  less  re- 
sistance to  the  causes  of  disease  in  persons  who  habitually  lead  an  active 
life,  and  in  those  who  work  hard  nearly  every  day"  (Barthez). 

Cold  baths  are  another  sort  of  tonic,  and  a  very  potent  sort,  through 
the  calm  which  they  impress  upon  the  nervous  system — a  general,  uniform, 
equal  calm,  soon  followed  by  an  excentric,  general,  uniform  reaction,  full 
of  harmony  and  spontaneity.     This  happy  reaction,  aided  and  sustained 


RECONSTITUENT    REMEDIES.  69 

on  leaving'  the  bath  (which  never  should  be  prolonged  in  these  cases,  but 
should  last  eight  or  ten  minutes  in  water  cooled  gradually  to  25°,  24°,  20° 
=  77°,  75°,  08°  Fahr.)  by  dry  or  aromatic  frictions,  massage,  a  fortifying 
meal  whetted  by  cordials,  etc.,  is  indicated  by  a  physiological  fever,  which 
is  the  most  powerful  antagonist  of  nervous  maladies. 

A  general  fever  of  this  sort  silences  the  nervous  mobility  and  extin- 
guishes the  sympathies,  far  from  arousing  them,  as  the  physiological  school 
pretends.  "  The  fever  overwhelms,"  is  a  popular  expression  upon  which 
physicians  have  not  reflected  sufficiently.  Fever  is  the  type  of  salutary 
reactions.     It  is  the  leading  form  of  disease. 

When  to  the  tonic  effect  of  cold  we  can  add  massage  produced  at  the 
same  time  by  the  douche,  we  get  at  once  a  double  action,  which  gives  to 
the  nervous  system,  the  capillaries,  and  by  sympathy  to  the  whole  econ- 
omy, a  durable,  fortifying  impression  which  is  to  be  preferred,  in  cer- 
tain lymphatic  and  irritable  subjects,  to  the  internal  tonics  which  they 
usually  bear  so  poorly.  We  think  the  cold  douche,  in  the  hands  of  a  pru- 
dent physician,  called  upon  to  play  an  important  part  in  tonic  reconstitu- 
ent  treatment.  Dr.  Fleury,  wlio  has  specially  studied  the  influence  of  this 
precious  remedy,  sums  up  his  experience  in  the  following  propositions, 
which  are  based  on  principles  like  our  own,  and  form  a  natural  part  of  the 
present  statement. 

1.  Stimulant  cold  douches  should  be  placed  in  the  first  rank  among 
reconstitueut  remedies,  in  virtue  of  their  action  upon  the  capillary  circu- 
lation, and  consecutively  upon  the  composition  of  the  blood,  calorification, 
nutrition,  and  innervation. 

2.  More  rapidly  and  surely  than  any  known  hygienic  and  pharmaceu- 
tic remedies,  they  modify  the  lymphatic  temperament  and  substitute  an  ac- 
quired sanguine  temperament.  This  happy  influence  seems  to  have  been 
attributed  to  a  double  action  :  one  upon  nutrition  and  the  composition 
of  the  blood,  the  other  upon  the  capillary  vessels,  the  vital  contractile 
powers  of  which  are  so  aroused  as  to  cause  blood-globules  to  penetrate 
vessels  which  previously  admitted  only  serum.  Cold  douches  further  ex- 
ercise a  very  favorable  influence  upon  the  development  of  the  bod\'  and 
the  muscles,  and  the  establishment  of  menstruation. 

3.  Five  3-oung  girls,  from  eighteen  to  twenty-two  years  of  age,  for 
several  years  subject  to  confirmed,  grave,  rebellious  chlorosis,  which  had 
resisted  all  known  hygienic  and  pharmaceutic  modifiers,  were  treated  by 
cold  douches;  all  recovered;  the  duration  of  treatment  was  seven  months 
in  the  longest  case,  two  in  the  shortest,  and  four  in  the  average. 

The  effect  was  always  the  same,  at  first  appearing  in  the  digestive 
and  muscular  apparatus,  then  in  the  nervous  system,  and  lastly  in  the 
blood  and  circulation, 

4.  Idiopathic  anosmia  and  anaemia  in  convalescents  disappear  quickly 
under  the  influence  of  cold  douches,  owing  to  their  action  on  digestion, 
nutrition,  and  the  muscular  system — an  action  which  aids  the  restoration 
of  blood  better  than  that  of  any  other  remedy. 


70  THERAPEUTICS. 

5.  In  symptomatic  anaemia  connected  with  certain  uterine  affections 
(displacement  and  engorgement),  with  old  obstinate  neuralgias,  certain 
neuroses,  and  hypertrophy,  cold  douches  have  a  double  curative  effect, 
curing  both  simultaneously,  and  often  the  one  by  means  of  the  other. 

6.  In  anaemia  with  abundant  and  repeated  haemorrhage,  cold  douches 
have  a  very  remarkable  double  action;  by  producing  i-enovation  of  the 
blood,  and  combating  organic  congestions,  they  diminish  or  arrest  the 
haemorrhage  which  had  been  aided  by  the  anaemia  they  produced;  thus 
helping  the  patient  to  break  the  vicious  circle  which  is  so  often  seen  in 
practice. 

7.  In  anaemia  in  a  curable  affection  which  is  not  influenced  by  cold 
douches,  the  latter  render  important  service  by  improving  the  patient's 
general  state  and  thus  rendering  the  treatment  and  the  cure  of  the  pri- 
mary affection  more  easy. 

8.  In  aniigmia  joined  to  an  incurable  affection,  cold  douches  are  often 
very  useful;  they  have  remarkably  improved  the  condition  of  several  pa- 
tients with  pulmonary  emphysema,  organic  affection  of  the  heart,  cancer, 
and  abdominal  tumors. 

We  close  this  part  of  our  treatise  by  observing,  first,  that  all  those 
organic  reactions  which  are  effected  by  the  most  general  and  rudimen- 
tary acts — by  the  functions  which  M.  Recamier  calls  common  vital  acts — 
such  reactions  as  fever  and  inflammation,  are  the  most  legitimate,  the 
most  calculable,  the  most  critical,  the  most  salutary. 

Those  reactions  of  the  system  which  are  effected  by  special  acts  and 
without  involving  the  common  vital  functions,  are  characterized  by  di- 
rectly opposite  traits;  such  are  all  the  nervous  diseases;  they  are  incal- 
culable in  their  course,  incoherent  in  their  symptomatic  expressions, 
without  critical  tendency,  incapable  of  furnishing  criteria  for  judging  them- 
selves. 

Thus  the  former,  dependent  on  the  common  vital  functions  shared  in 
by  every  living  being,  occur  with  harmony,  unity;  have  calculable  peri- 
ods, a  term  to  which  one  can  assign  a  date  and  a  mode. 

The  latter  are  manifested  by  anomalies  in  the  action  and  influence  of 
the  special  functions  (those  which  exist  only  in  certain  animals),  go  on 
without  order,  without  harmony,  have  nothing  calculable,  persist  indefi- 
nitely, and  cannot  be  foretold  in  the  succession  of  their  symptoms," or  in 
their  modes  of  termination. 

Nevertheless,  observation  informs  us  that  these  two  classes  exclude 
each  other,  and  that  a  substitution  of  the  first  for  the  second  is  desir- 
able, because  the  most  natural  solution  —  a  result,  as  we  have  seen,  of 
their  respective  characters.  (For  a  fuller  development  of  these  ideas,  see 
the  inaugural  thesis  of  one  of  us:  "  Essai  sur  les  lois  de  la  force  medica- 
trice,"  Paris,  fevrier,  1835,  No.  36.) 

The  analeptic  tonics  make  the  common  vital  functions,  the  force  of 
assimilation,  predominate  in  the  organism,  and  consequently  cause  the 
most  calculable,  legitimate,  and  salutary  reactions. 


EECONSTITUENT    EEMEDIES.  71 

Therefore,  they  are  the  true  and  natural  remedies  for  the  nervous 
affections  which  we  have  here  mentioned. 

The  last  argument  which  we  shall  bring  in  support  of  this  capital 
therapeutic  law  is  one  which  we  have  learnt  from  a  thousand  daily  obser- 
vations, to  wit:  that  constitutions  characterized  by  predominance  of  the 
assimilative  force  are  not  subject  to  nervous  diseases,  but  are  easily  put 
into  a  well-marked  fever  in  all  the  morbid  reactions  they  have  to  endure; 
but  those  of  a  nervous  temperament,  and  much  subject  to  spasms  or  dis- 
eases of  the  nerves  in  either  sex,  rarely  experience  fever  and  seldom  react 
by  pyrexias. 

If  to  this  be  added  what  is  to  follow  under  antispasmodic  medicine, 
in  reference  to  palliation  of  essential  nervous  diseases,  we  dare  to  hope 
that  we  shall  have  given  the  fundamental  jjrinciples  for  the  treatment  of 
this  numerous  and  important  class  of  disease. 

Sydenham  felt  clearly  the  need  of  having  at  his  disposal  two  classes 
of  resources  in  treating  these  diseases,  and  could  employ  the  antispasmo- 
dics simultaneously  or  alternatively,  as  is  seen  in  the  following:  "  Quoties 
vero  paroxysmus  invaserit,  si  tale  aut  tantum  sit  malum  ut  inducias  ferre 
nolit,  donee  sanguine  et  spiritibus  corroboratis,  quasi  per  ambages  sanari 
possit,  confestim  ad  remedia  hysterica  ista  confugiendum  est,  qua3  odore 
viroso  ac  gravi,  spiritus,  ut  dixi,  exorbitantes  ac  desertores  in  proprias 
stationes  remandant,  sive  intra  corpus  sumantur,  sive  naribus  admoveatur 
odorando,  sive  externis  applicentur;  cujus  modi  sunt  asa-foetida,  galbanum, 
castoreum,  spiritus  salis  ammoniaci  et  quicquid  est  denique  quod  odorem 
tetrum  admodum  ingratumque  spirat"   (Syd:  "  Op.,"  t.  I.,  p.  276.) 

It  were  to  be  wished  that  all  the  diseases  of  nerves  were  included  in 
this  class  which  we  have  described.  But  unfortunately,  the  neuroses,  dis- 
eases without  material,  like  the  phlegmasia,  the  diacrises,  etc.,  are  the 
morbid  manifestation  of  all  known  diatheses,  and  to  these  tonic  treatment 
is  rarely  applicable,  while  iron  is  usually  hurtful. 

It  is  also  very  necessary  to  recollect  what  we  have  taken  pains 
to  show,  by  pathological  arguments  which  we  perhaps  have  carried  too 
far,  namely:  that  an.-emia  or  cachexia  has  its  species,  like  inflammation; 
and  that,  as  there  are  scrofulous,  venereal,  gouty,  dartrous  phlegmasia?, 
etc.,  there  are  antemise  or  cachexias  which  are  symptomatic  of  all  these 
diatheses.  In  these  an.'emias,  also,  iron  is  almost  always  contraindicated. 
Unless,  then,  we  wish  to  compromise  the  general  principles  laid  down  in 
this  chapter,  we  must  apply  them  only  to  the  class  of  nervous  diseases 
and  to  the  sorts  of  ana?mia  which  we  have  carefully  distinguished. 


CHAPTER  11. 

ASTRINGENTS. 

Tannin. 

We  shall  speak  very  briefly  of  the  employment  of  pure  tannin,  and 
more  at  length  of  remedies  of  which  it  forms  a  considerable  ingredient. 

From  its  solubility  and  the  ease  with  which  it  is  given,  it  is  used 
in  all  cases  where  astringents  are  recommended. 

Internally,  in  chronic  diarrhoeas,  the  dose  is  1 — 5  centigrammes  (gr. 
O'lo. — O'To)  for  children,  5—50  centigrammes  (gr.  0'75 — 7 '5)  for  an  adult. 
In  severe  haemorrhages,  10  centigrammes  (gr.  1'5)  every  two  hours,  till  four 
grammes  (60  grains)  have  been  taken.  In  chronic  blennorrhagia,  pul- 
monary and  uterine  catarrh,  in  the  dose  of  25 — 50  centigrammes  a  day, 
for  one  or  two  months. 

M.  Charvet,  professor  at  the  secondary  school  of  medicine  at  Grenoble, 
has  used  tannin  with  advantage  in  the  sweating  of  phthisical  patients, 
given  in  the  dose  of  2^ — 10  centigrammes  (0'4 — 1'5  gr.)  during  the  24 
hours,  usually  in  the  evening,  and  with  opium. 

M,  Mialhe,  guided  by  his  chemical  theory  of  albuminuria,  proposed  to 
combat  this  affection  with  tannin.  It  has  been  thus  employed  by  several, 
not  without  some  advantage.  M.  le  docteur  Garnier  and  Dr.  Tilling,  of 
the  province  of  Venice,  among  others,  have  shown  that  in  the  high  dose 
of  2 — 4  grammes  (30 — GO  gr.),  associated  with  cinchona,  it  modifies  spe- 
cially and  notably  the  anasarca  which  accompanies  albuminuria.  Besides, 
the  urine  itself  is  seen  to  become  more  abundant,  and  by  degrees  to  regain 
its  physiological  character;  at  the  same  time  the  patient  regains  apjoetite 
and  strength;  in  a  word,  the  chief  symptoms  improve  quite  rapidly, 
sometimes  from  the  first  days.  But,  to  avoid  mistakes,  we  must  add  that 
these  good  results  are  scarcely  obtained  except  in  acute,  or  at  least  quite 
recent,  albuminuria,  that  is,  where  the  lesion  of  the  kidney  is  slight  or 
superficial;  while,  in  an  advanced  case  of  Bright's  disease,  tannin  fails  or 
is  not  lasting  in  its  effects. 

M.  Chansarel,  of  Bordeaux,  whose  father  made  most  interesting  experi- 
ments on  tannin,  published  in  the  Bulletin  medical  de  Bordeaux  (octobre, 
1810)  a  memoir  on  its  therapeutical  use.  This  paper  (perhaps  a  trifle  ex- 
aggerated in  its  claims)  places  tannin  among  the  most  useful  of  drugs. 
In  addition  to  the  curative  powers  above  mentioned,  he  speaks  of  some 
which  are  still  more  precious.  He  found  that  it  cured  intermittent  fevers 
as  well  as  sulphate  of  quinine;  for  which  purpose  he  gives  a  progressive 


ASTRINGENTS.  73 

dose,  rising  from  60  centigrammes  to  2  grammes  (9  to  30  grains)  in  150 
grammes  (nearly  5  ounces)  of  water  and  mucilage  of  gum  arable.  Of 
this  solution  the  patient  takes  a  dessertspoonful  every  three  hours  during 
the  intervals  of  the  disorder.  This  only  confirms  what  is  said  by  Pez- 
zoni  ("  Histoire  de  la  Societe  de  medecine  pratique  de  Montpellier," 
1807.) 

Dr.  Leriche,  of  Lyons,  has  very  lately  demonstrated  beyond  a  doubt 
the  excellent  effects  of  tannin  as  a  substitute  for  cinchona  in  intermit- 
tent fevers.  These  results  are  quite  in  accord  with  our  views  regarding 
the  mode  of  action  of  cinchona  or  sulphate  of  quinia  as  an  antiperiodic; 
that  is,  in  our  view  this  property  in  tannin  (though  exaggerated  by  these 
different  authors)  may  well  he  only  the  consequence  of  the  tonic  as- 
tringent and  reconstituent  properties  which  it  possesses  in  a  very  high 
degree. 

M.  Chansarel  also  prescribes  it  as  an  anthelmintic:  "  Children  who 
have  taken  it  in  syrup  or  draughts  or  injections,  in  the  dose  of  30 — 50 
centigrammes  (4*5 — 7*5  gr.)  have  been  perfectly  cured,  and  have  passed 
a  large  quantity  of  worms  "  {Ibid). 

Finally,  we  must  not  omit  its  virtues  as  an  antidote.  According  to 
M.  Chansarel,  it  is  a  certain  antidote  in  poisoning  by  verdigris  and  other 
salts  of  copper,  lead  and  the  saturnine  preparations,  tartar  emetic  and 
the  preparations  of  antimony,  cantharides,  opium  and  its  compounds,  co- 
nium,  hyoscyamus,  stramonium,  the  organic  alkalies  in  general,  mush- 
rooms, etc.  (Chansarel:  Journal  de  la  Societe  de  medecine  de  JBordeaux, 
2*  serie,  t.  VIII.,  p.  316.)  Without  sharing  in  this  enthusiasm,  we  yet 
recognize  very  gladly  that  it  has  evident  value  in  the  above  cases  of  pois- 
oning. 

The  astringent  property  of  tannin  has  suggested  to  M.  Woillez  its  use 
in  the  catarrhal  element  of  diseases  of  the  respiratory  passages.  He  says 
that,  when  given  in  pills  of  0*15  grammes  (2^  gr.)  until  sixty  per  day  have 
been  taken,  it  promptly  affected  acute  bronchitis,  which  seemed  to  be  pass- 
ing off  too  slowly.  In  these  cases  the  quantity  of  sputa  expectorated  and 
of  rales  heard  diminished  remarkably  from  day  to  day.  M.  Woillez,  think- 
ing that  this  effect  was  produced  by  moderating  the  bronchial  circulation, 
was  led  to  use  tannin  in  pulmonary  bronchial  congestion,  and  particu- 
larly in  typhoid  fever.  He  has  such  confidence  in  the  action  of  tannin  in 
relieving  congestion  of  the  lung  that  he  considers  the  remedy  a  touch- 
stone to  diagnosticate  phthisis,  since  after  the  disappearance  of  congestion, 
the  bruit  which  remains  must  all  be  laid  to  an  organic  affection.  But 
this  test  is  scarcely  possible  except  in  atonic  phthisis,  for  (as  M.  Woillez 
admits)  tannin  aggravates  febrile  and  erethic  phthisis  {Sidl.  de  tli'era- 
peutique,  1863).  * 

Externally,  as  a  gargle,  the  dose  is  4  grammes  (60  gr.)  to  250  grammes 
(8  oz.)  of  water,  in  chronic  inflammations  of  the  buccal  and  pharyngeal 
mucous  membrane.  In  powder,  like  snuff,  for  rebellious  epistaxis  and 
acute  or  chronic  coryza.     In  injection,  in  vaginal  and  urethral  blennorrha- 


74  THERAPEUTICS. 

gia,  in  the  dose  of  10 — 50  centigrammes  (1'5 — 7'5  gr.)  to  30  grammes  (1 
ounce)  of  vehicle.  As  a  rectal  injection,  in  proctorrhoea,  chronic  diar- 
rhoea, chronic  dysentery,  in  the  dose  of  1 — 1-^  grammes  to  500  grammes 
of  water  (15 — 22  grains  to  IG  ounces).  In  coilyria,  in  catarrhal  ophthal- 
mia, 10 — 20  centigrammes  to  30  grammes  of  water  (I'S — 3  gr,  to  the  ounce). 
In  ointments,  for  local  treatment  of  dartres  and  fissure  of  the  anus.  With 
glycerine,  it  has  succeeded  in  certain  rebellious  forms  of  herpes,  especi- 
ally h.  prjeputialis.  Plugging  the  vagina  with  a  mixture  of  glycerine,  80 
grammes  (2^  oz.)  and  tannin  20  grammes  (5  drachms)  (Demarquay),  has 
been  found  very  useful  in  acute  and  chronic  vaginitis.  The  plug  is  to  be 
renewed  every  twenty-four  hours.  The  tannin  ointment  has  just  the  same 
virtues. 

(Glycerate  of  tannin.) 

IJ.     Powdered  tannin 10  grammes=154  grains. 

Glycerate  of  starch 50         "        =770       " 

Mix  with  care. 

Tannin,  employed  locally  like  alum,  has  recently  been  lauded  by  some 
in  the  treatment  of  croupous  and  even  diphtheritic  angina.  But  it  is 
more  useful  in  cedematous  laryngeal  angina,  when  water  strongly  charged 
with  tannin  is  thrown  in  vapor  into  the  throat,  by  a  pulverizer. 

To  lessen  the  cutaneous  inflammation  in  erysipelas,  we  are  accustomed 
to  spread  with  a  pencil  upon  the  affected  part  a  layer  of  a  solution  of 
tannin  20  grammes  (  3  v.),  camphor  40  grammes  (  3  x.),  sulphuric  ether  100 
grammes  (  3  xxv.).  The  ether  in  evaporating  leaves  tannin  and  camphor 
in  powder  on  the  skin,  which  acts  as  a  sedative  and  resolvent. 

As  an  epithem  it  is  applied  to  the  skin  to  contract  the  tissues,  re- 
solve npevi  materni,  etc.  Associated  with  benzoin  and  applied  to  the  pus- 
tules of  small-pox  from  the  outset,  it  is  proposed  by  M.  Homolle  as  an 
abortive,  especially  for  the  face,  to  prevent  disfiguring  cicatrices. 

Finally,  M.  Mialhe  uses  a  solution  of  tannin  to  show  in  the  urine  a 
species  of  albumen  which  is  not  precipitated  by  nitric  acid,  called  albu- 
minose. 

M.  Debauque,  a  pharmacist  of  Antwerp,  was  the  first  to  show  that 
iodine  is  soluble  by  tannin.  Following  this  indication,  M.  Boinet  made  it 
a  general  rule  to  use  as  a  vehicle  for  iodine  some  astringent  syrups  which 
contain  tannic  acid,  such  as  the  antiscorbutic  syrups,  syrups  of  horse-rad- 
ish, gentian,  walnut,  cinchona,  bitter-orange  peel. 

Combhiation  of  iodine  xoith  tannin,  or  liqueur  iodo-tannique. — A 
direct  association  of  these  two  bodies  has  been  lately  effected  by  MM. 
Socquet  and  Guilliermond  (of  Lyons).  In  this  combination  iodine  is  sol- 
uble, is  deprived  of  its  caustic  properties  and  its  smell,  without  losing  any 
of  its  therapeutical  virtues.  It  is  claimed  that,  in  this  form,  the  iodine 
is  much  more  active  than  in  iodide  of  potassium,  and  presents  none  of 


ASTRINGENTS.  75 

the  inconveniences  which  exist  when  iodine  is  diluted  with  an  inert  sub- 
stance. 

The  authors  have  obtained  by  this  chemical  composition  two  solu- 
tions: one  called  neutral,  because  starched  paper  indicates  no  trace  of 
iodine,  which  is  capable  of  dissolving,  in  addition,  a  quantity  of  iodine  equal 
in  weight  to  half  the  tannin  used;  the  second  is  the  result  of  this  addi- 
tion, and  is  called  ioduretted  iodo-tannic  solution. 

Tannin  from  rhatany  has  been  preferred  by  the  authors  because  it  has 
less  astringency  than  Cjuercitannin;  the  latter  is  reserved  for  external  use. 

The  syrup  prepared  from  the  iodo-tannic  solution  is  very  limpid,  rof  a 
splendid  red  color,  and  agreeable  to  the  taste;  30  grammes  of  syrup  con- 
tain 6  centigrammes  of  iodine  (2  parts  in  1,000).  This  amount  (nearly 
fi.)  is  the  dose  to  begin  with;  it  may  easily  be  increased  to  twice  that 
quantity  per  day. 

The  solution  for  external  use,  prepared  with  quercitannin,  contains 
0  grammes  of  iodine  to  100  of  vehicle. 

We  will  not  mention  the  numerous  advantages  attributed  to  this  very 
rational  combination.  It  is,  however,  a  very  recent  importation,  is  not 
well  defined  chemically,  and  we  have  no  experience  of  our  own  to  enable 
us  to  decide  upon  its  merits. 

We  must  add  that  M.  Barrier,  of  Lyons,  has  used  the  iodo-tannic  so- 
lution externally,  in  injections  for  fistulfe  resulting  from  cold  abscesses,  - 
and  in  hydrocele,  in  which  he  states  that  he  has  obtained  as  good  results 
as  from  tincture  of  iodine. 

He  has  also  employed  this  agent  as  a  coagulant  of  the  blood.  Inject- 
ed into  varices,  it  has  produced  a  less  prompt  action  than  perchloride 
of  iron,  but  very  analogous.  Here  is  a  subject  for  fresh  surgical  experi- 
ment {Gazette  hebdomadaire,  mars,  1854). 

M.  Desgranges,  of  Lyons,  has  continued  these  experiments  on  the  li- 
queur iodo-tannique,  and  attests  its  astringent  and  hsemospastic  property, 
which  he  attributes  exclusively  to  the  tannin,  and  not  to  the  iodine. 
Both  are  taken  up  b^  absorption,  while  the  perchloride  is  not  absorbed. 
He  concludes  that  this  compound  is  likely  to  be  as  useful  in  surgery  as 
in  medicine  (  Gazette  medicale  de  Lyon,  mai,  1854;    Union,  1854). 

Tannate  of  Qiihiia. — This  compound  is  a  new  preparation,  intro- 
duced by  M.  Barreswil. 

Berzelius  foresaw  the  advantages  of  this  compound,  arguing  from  the 
theoretical  idea  that,  while  quinine  is  the  chief  active  ingredient  in  cin- 
chona, the  tannin  contained  in  the  bark  must  have  a  share  in  the  effect. 

A  commission  named  by  the  Academy,  and  reported  by  M.  Bouvier, 
subjected  this  new  compound  to  numerous  experiments,  and  found  that 
it  possessed  a  power  at  least  equal  to  that  of  sulphate  of  quinia,  both  in 
intermittent  fevers  and  in  acute  rheumatism  and  certain  neuralgias. 

In  addition  to  its  antiperiodic  and  sedative,  or  contra-stimulant  prop- 
erties, which  it  shares  with  sulphate  of  quinia,  certain  quite  sj^ecial  vir- 
tues have  been  attributed  to  tannate  of  quinia. 


76  THERAPEUTICS. 

The  first  of  these  is  that  the  tannate  is  much  cheaper,  and  for  this 
reason  is  suited  to  country  practice.  A  second  advantage  is  that  it  is 
very  much  less  bitter;  and,  finally,  it  does  not  irritate  the  digestive  organs 
as  sulphate  of  quinia  sometimes  does. 

The  dose  has  been  stated  as  nearly  the  same  as  that  of  the  sul- 
phate; but  later  trials  show  that  the  dose  ought  to  be  a  little  larger,  in 
order  to  act  surely  in  intermittents. 

It  is  said  to  be  not  only  an  excellent  febrifuge,  but  a  very  potent 
tonic.  In  the  dose  of  20  centigrammes  daily  (3  grains),  it  is  claimed  to 
be  one  of  the  most  valuable  and  meritorious  "  reconfortants."  It  has  been 
proposed  as  a  remedy  for  phthisical  night-sweats,  in  which  case  it  would 
be  indicated  by  its  double  quality  as  tonic  and  antiperiodic. 

With  all  these  advantages,  some  of  which  are  real,  and  some  require 
to  be  better  verified,  one  objection  is  made  to  the  tannate,  namely,  its 
amorphous  and  insoluble  form,  and  the  consequent  facility  with  which  it 
may  be  adulterated, 

A  fresh  study  of  tannate  of  quinia  must  be  made;  and  in  order  to 
procure  it  of  a  definite  composition,  tlie  admirable  directions  of  Regnault, 
lately  presented  to  the  Academy  of  Medicine,  may  be  followed  : 

1.  The  pure  tannate  of  quinia  cannot  be  obtained  by  simple  precipita- 
tion of  tlie  acetate  of  quinia  by  a  solution  of  galio-tannic  acid  (tannin 
from  gall-nuts),  a  procedure  very  generally  recommended. 

2,  The  compound  resulting  from  the  reaction  of  tannin  upon  the  basic 
and  neutral  sulphates  of  quinia  retains  a  portion  (about  3  per  cent.)  of 
sulphuric  acid,  which  cannot  be  removed.  It  forms  a  sort  of  sulpho-tan- 
nic  varnish,  different  in  composition  and  properties  from  the  tannate 
proper. 

3.  When  basic  sulphate  is  dissolved  by  the  help  of  acetic  acid  (method 
of  Barreswil),  the  precipitate  is  also  sulpho-tannic.  Owing  to  the  pres- 
ence of  acetic  acid,  the  water  used  to  wash  this  substance  retains  about 
one-fifth  of  the  total  amount  of  tannate  of  quinia;  this  fifth  may  be  re- 
covered by  neutralization  with  bicarbonate  of  soda. 

4.  The  formula  of  the  Strasburg  phariiiacopceia  should  not  be  adopted, 
as  its  proportions  render  it  impracticable,  and  it  requires  an  amount  of 
quinia  nearly  twice  that  found  in  tannate  prepared  chemically  by  double 
decomposition. 

5,  The  method  described  in  my  memoir  gives  a  regular  and  identical 
result;  the  directions  are  as  follows:  into  an  aqueous  solution  of  acetate 
of  quinia  such  a  proportion  of  purified  tannic  acid  is  poured  that  the  pre- 
cipitate formed  at  the  beginning  of  the  process  is  redissolved  entirely. 
This  liquid,  carefully  neutralized  by  bicarbonate  of  soda,  throws  down 
tannate  of  quinia,  which  is  easily  washed  and  of  uniform  composition, 

6,  As  thus  prepared,  tannate  of  quinia  contains  on  an  average  20'5 
per  cent,  of  quinia,  and  corresponds  to  a  definite  compound  Cjo  H24  Nj  O4 
—  2  (C54  H22  O34),  in  which  tribasic  tannic  acid  is  in  excess  relative  to  the 
quinia,  a  diacid  alkaloid. 


I 


ASTRINGENTS.  77 

7.  The  physical  coefficient  of  solubility  of  tannate  of  quinia  in  water 
cannot  be  determined,  because,  under  the  chemical  influence  of  water, 
the  salt  slowly  decomposes  into  gallo-taniiic  acid,  which  dissolves  a  small 
part  of  the  tannate,  and  a  more  basic  tannate  which  remains  dissolved. 

8.  Tannate  of  quinia  is  quite  soluble  in  aqueous  solutions  of  the  or- 
ganic acids,  which  do  not  precipitate  the  tannic  acid  from  these  solutions. 
It  is  not  soluble,  at  least  not  immediately,  in  the  mineral  acids,  which 
have  the  property  of  producing  in  liquids  containing  tannin  those  insolu- 
ble deposits  studied  by  Strecker. 

9.  In  physiological  and  therapeutical  experiments,  it  is  well  to  note 
that  1  gramme  of  neutral  sulphate  of  quinia  is  equivalent  to  3'50  grammes 
of  pure,  dry  tannate. 

M.  Vulpian  is  now  comparing  the  properties  of  pure  tannate  with 
those  of  the  sulpho-tannic  combinations  which  have  often  taken  its  place 
in  ordinary  medicine.     The  results  will  be  presented  to  the  Academy. 

Tannates  of  lead,  zinc,  bismuth. — Tannate  of  lead,  as  used  in  medi- 
cine, is  a  bitannate  obtained  by  precipitating  a  concentrated  infusion  of 
gall-nuts,  or  better,  a  solution  of  tannin  by  liquid  acetate  of  lead. 

Autenrieth  and  M.  Yoth  have  praised  it  in  the  treatment  of  gangre- 
nous ulcers.  M.  Ricken  has  prescribed  it  with  success,  to  cicatrize  the 
bed-sores  of  phthisical  and  typhoid  patients. 

Tannate  of  zinc  has  been  used  under  the  name  of  "  Sel  de  Barnit,"  in 
the  treatment  of  gonorrhoea, 

A  tannate  of  bismuth  has  been  introduced  by  M.  Cap,  who  obtains  it 
by  dissolving,  in  water  acidulated  with  nitric  acid,  44  grammes  of  crystal- 
lized nitrate  of  bismuth,  and  precipitating  by  a  slight  excess  of  soap- 
maker's  lye.  The  precipitate  is  collected  and  washed,  and  triturated  in 
a  mortar  with  20  grammes  of  tannin;  a  paste  is  made  with  water,  which 
is  placed  on  a  cloth,  washed,  and  dried. 

It  may  also  be  obtained  by  precipitation.  In  spite  of  the  efforts  of 
MM.  Aran  and  Bouchut,  who  recommended  it  as  a  good  astringent,  it  is 
now  almost  abandoned. 

Oak-bark,  Tan. 

Oak-bark  owes  all  its  virtues  to  tannin  and  gallic  acid. 

A  very  remarkable  fact  has  been  observed  at  the  Veterinary  School 
of  Lyons.  Large  doses  of  oak -bark  were  given  to  horses  and  goats.  A 
horse  who  had  taken  10  kilogrammes  in  a  month  (300  ounces  Troy),  had 
redder,  more  viscous,  more  consistent  blood  at  the  autopsy;  his  body  re- 
mained two  months  without  giving  signs  of  putrefaction,  whereas  horses 
putrefy  in  a  very  short  time,  even  in  winter,  if  it  does  not  freeze  ("  Compte- 
rendu  des  travaux  de  I'ecole  veterinaire  de  Lyon,"  1811).  Hence  the 
direction  to  give  large  doses  of  tannin  internally  when  gangrene  threat- 
ens to  invade  a  limb  after  severe  wounds;  the  principle  does  not  apply  to 
dry  gangrene.     The  mortified  parts  ought  also  to  be  covered  with  tannin 


78  THERAPEUTICS. 

to  arrest  the  progress  of  putrefaction.  It  is  for  experience  to  decide  how 
far  tan  should  be  given  in  various  forms  of  typhoid  disease. 

Porta  {Revue  niedicale,  t.  TIL,  p,  493)  has  given  oak-bark  internally 
in  active  and  passive  hEemorrhages.  He  prescribes  it  in  the  dose  of  2^ 
grammes  (38  gr.)  daily,  which  is  plainly  too  little.  Topically,  the  decoc- 
tion has  been  used  in  haemorrhages,  leucorrhoea,  blennorrhagia — in  a 
word,  in  all  cases  where  tannin  and  rhatany  have  been  recommended. 

Lightermen  sprinkle  their  shoes  with  tan  when  they  leave  their  work, 
thus  preventing  the  increase  or  development  of  the  trouble  which  they 
call  grenouille,  which  is  a  softening  of  the  derma  with  alteration,  with 
cracks  and  often  wasting  of  the  tissues  which  are  much  in  contact  with 
water.  It  occurs  on  the  heel,  below  the  tendo-Achillis,  etc.,  especially 
between  the  toes;  it  is  easy  to  see  how  the  remedy  acts. 

The  febrifuge  virtues  of  tan  seem  very  doubtful  to  us,  in  spite  of  what 
Cullen  may  have  said  in  his  "  Materia  Medica  "  (t.  IL,  p.  47).  As  regards  the 
fact  stated  by  Barbier  of  Amiens  ("  Matiere  medicale,"  t.  I.,  p.  328),  that 
in  a  suburb  of  Amiens  there  is  a  tan-mill  where  the  laborers  never  have 
intermittent  fever,  while  those  who  work  at  other  employments  in  the 
neighborhood  are  often  affected,  we  do  not  question  it,  since  Barbier 
affirms  it;  but  since,  in  other  parts,  those  who  grind  tan  take  intermittent 
fever  like  other  people,  we  think  the  immunity  in  these  cases  must  be 
due  to  circumstances  which  have  escaped  Barbier's  observation. 

The  acorns  of  quercus  ilex  are  eatable;  those  of  q.  robur  are  scarcely 
eaten  except  by  beasts.  But  both  kinds  are  used  in  medicine,  after  being 
roasted  like  coffee;  they  contain  nearly  one-tenth  part  of  tannin.  They 
are  afterwards  ground  fine,  and  from  the  powder  a  liquid  is  prepared  as 
coffee  is  made,  which  has  exactly  the  color  of  the  latter,  and  tastes  pleas- 
antly, especially  when  milk  is  added.  This  sort  of  coffee  is  very  useful 
for  children  after  weaning,  when  they  have  those  obstinate  non-febrile 
diarrhoeas.  It  is  also  useful  to  persons  whose  digestion  is  laborious  and 
who  are  subject  to  looseness.  In  a  word,  it  may  be  given  as  coffee  to 
irritable  patients  whose  digestive  functions  are  hindered  by  a  chronic 
phlegmasia. 

Walnut,  "Walnut-husk. 

For  twenty  years  past  the  leaves  of  the  walnut  have  enjoyed  a  high 
repute,  as  astringents,  tonics,  and  detersives.  But  their  chief  fame  has 
been  as  an  antiscrofulous  remedy;  there  was  even  a  time  when  they  were 
thought  a  true  specific  against  scrofula. 

Jurine,  of  Geneva,  seems  to  have  been  one  of  the  first  to  use  the  ptisan 
of  walnut-leaves  for  lymphatic  engorgements.  Dr,  Psorson,  of  Chambery, 
recalling  the  successes  of  the  professor,  gave  it  to  a  beggar  with  old 
scrofulous  ulcers,  and  by  the  influence  of  this  remedy  alone,  in  ptisans, 
lotions  and  cataplasms,  obtained  quite  a  rapid  cure;  since  when  he  has 
continued  to  employ  it  with  advantage. 


ASTRINGENTS.  79 

In  France,  Dr.  Negrier,  of  Angers,  has  tried  the  walnut-leaves  on  a 
very  large  scale,  and  lias  published  several  interesting  memoirs  upon  the 
subject.  Perhaps  he  was  wrong  in  ascribing  to  this  remedy  an  almost 
specific  virtue.  But,  allowing  for  a  little  exaggeration,  we  must  admit 
our  debt  to  him  for  having  pointed  out  the  value  of  walnut  in  the 
various  forms  of  scrofula. 

The  effects  produced  by  the  internal  use  of  extract  of  walnut-leaves 
are  at  first  general:  the  influence  of  the  remedy  upon  local  symptoms  ap- 
pears later.  The  action  is  generally  slow,  requiring  from  twenty  to  fifty 
days,  according  to  the  nature  of  the  symptoms  and  the  constitution  of 
the  subject  before  the  effects  become  sensible. 

In  non-ulcerated  strumous  glands  the  action  is  not  seen  for  quite  a 
long  time;  while  in  ulcers  and  fistulous  openings,  whether  kept  up  by 
bony  caries  or  not,  the  action  is  quite  prompt.  But  their  final  cure  is  sure 
to  require  a  long  time,  which  makes  it  sometimes  impossible  to  ascertain 
the  exact  part  played  by  the  remedy,  and  that  by  time. 

Finally,  the  author  values  the  remedy  very  highly  as  a  collyrium  in 
scrofulous  ophthalmia. 

The  resolvent  and  detergent  properties  of  walnut-leaves  are  often 
made  useful;  many  employ  the  decoction  to  advantage  as  an  injection  in 
the  treatment  of  leucorrhoea  and  chronic  metritis. 

M.  Vidal  (de  Cassis)  has  advised  the  injection  of  this  decoction  into 
the  uterine  cavity,  to  cure  catarrh  of  the  organ.  But  MM.  Bretonneau 
and  Hourmann  have  shown  beyond  a  doubt  the  extreme  danger  of  such 
injections,  which,  reaching  the  peritoneal  cavity  through  the  tubse,  may 
cause  fatal  peritonitis.  (Hourmann:  Journal  des  connaissances  medico- 
chirtirgicales,  octobre,  1840).  Dr.  Cazin,  of  Boulogne,  has  used  the  de- 
coction of  the  leaves,  or  the  husk,  as  gargles,  from  the  beginning  of  ton- 
sillitis, and  says  that  he  has  often  aborted  the  inflammation. 

In  resume,  according  to  the  numerous  experiments  of  M.  Ncgrier,  of 
Angers,  which  have  been  verified  by  a  large  number  of  physicians,  it 
seems  incontestable  that  walnut-leaves,  though  certain  claims  in  regard 
to  their  marvellous  virtues  in  scrofula  may  not  be  proved,  are  very  useful 
in  that  affection.  We  will  add  that,  owing  to  their  resolvent  and  deter- 
gent powers,  they  give  good  results  in  the  ti-eatment  of  old  ulcers,  and 
still  better  in  chronic  catarrhs  of  the  different  mucous  membranes. 

In  a  communication  made  to  the  Academy  of  Medicine  some  jj^ears 
ago.  Professor  Nelaton,  in  the  name  of  Dr.  Raphael,  of  Provins,  proposed 
the  fresh  leaves  and  root  of  walnut,  as  of  remarkable  virtue  in  malignant 
pustule  and  charbon.  It  appears  that  this  topical  application  had  succeeded 
brilliantly  in  the  hands  of  a  southern  practitioner.  Dr.  PomajTol;  while 
Dr.  Raphael  says  that  he  obtained  a  rapid  cure  in  four  patients  affected 
with  oedema  of  the  eyelids  in  charbon,  or  with  confirmed  malignant  pus- 
tule. In  spite  of  the  miraculous  nature  of  these  results,  which  we  may 
naturally  distrust,  we  have  not  thought  best  to  omit  mention  of  them. 

The  husk  owes  its  astringent  virtues  to  the  tannin  and  citric  and  malic 


80  THERAPEUTICS. 

acids  which  it  contains.  These  give  it  the  same  title  to  use  as  oak-bark, 
kino,  etc. ;  while  its  bitter  principle  gives  it  some  of  the  properties  of  the 
bitter  astringents. 

A  pleasant  liqueur  is  made  from  the  husk,  which  is  useful  in  sluggish 
digestion,  when  not  due  to  chronic  inflammation. 

Hippocrates  and  Dioscorides  recommended  the  husk  as  an  anthelmin- 
tic, to  be  given  as  an  extract,  in  the  dose  of  50  or  60  centigrammes  (7 — 9 
grains).  This  property  is  much  contested.  At  present  it  is  not  admitted 
to  possess,  in  infusion,  decoction,  or  extract,  any  higher  powers  than  be- 
long to  gentian  and  centaury. 

Pollini's  ptisan,  made  with  the  husks  of  walnut  and  various  other  ac- 
tive substances,  is  somewhat  popular  for  the  treatment  of  constitutional 
syphilis  and  inveterate  dartres;  we  do  not  attribute  to  it  an  anti-syphi- 
litic power  sufficient  to  enable  it  to  supplant  mercury  and  iodine,  or  a 
power  of  curing  dartres  without  the  aid  of  any  other  tonic,  but  it  is  a 
useful  adjuvant,  especially  when  the  severest  symptoms  have  subsided. 

UvA  Ursi,  Comfrey,  Whortleberry. 

The  uva  ursi  (arbutus  uva  ursi),  a  plant  of  the  family  of  the  ericaceae, 
enjoyed  during  the  last  century  a  reputation  to  which  Murray,  the  illus- 
trious author  of  the  "Apparatus  Medicaminum,"  contributed  not  a  little. 
In  this  work  may  be  read  the  tales  of  its  almost  miraculous  powers  in  the 
treatment  of  diseases  of  the  kidneys  and  the  urinary  passages.  It  is  still 
used  as  a  diuretic,  on  a  par  with  many  other  analogous  remedies,  but  no  more. 

But  uva  ursi  certainly  has  astringent  properties,  due  to  tannin  and 
gallic  acid,  which  it  contains  in  such  large  quantities  that  in  some 
parts  of  the  North  it  is  used  to  tan  leather  and  make  ink.  In  cases  where 
an  astringent  effect  is  desired  we  prescribe  the  decoction  of  the  leaves  in- 
ternally and  externally.  MM.  de  Beauvais,  Coslithes  and  Gauchet  {Bul- 
letin cle  therapeutique,  1861,  t.  II.,  p.  181),  have  lately  represented  it  as 
an  excellent  substitute  for  ergot  in  childbed,  to  excite  the  uterine  con- 
tractions and  arrest  hfpmorrhages  due  to  the  inertia  of  the  uterus.  The 
dose  given  is  from  4  to  8  grammes  (1  to  2  drachms)  of  the  powdered 
leaves  in  a  quart  of  ptisan,  or  if  the  extract  be  prescribed,  it  is  given  in 
the  dose  of  0"3  to  3  grammes  (4*5  to  45  gr. )  per  diem,  in  3  or  4  doses. 

M.  Braconnot  has  remarked  that  the  leaves  of  uva  ursi  are  often  re- 
placed by  those  of  vaccinium  vitis  idasa,  which  is  very  abundant  in  the 
Vosges.  They  are  distinguished  by  their  brownish  green  color;  they  are 
less  entire,  that  is,  are  slightly  dentate,  their  edges  always  fold  down- 
ward, their  transverse  nervures  are  very  apparent,  their  lower  surface  is 
spotted  with  very  remarkable  points. 

Uva  ursi  is  often  mixed  with  leaves  of  the  box  (buxus  sempervirens, 
L.,  of  the  euphorbiacefe) ;  they  are  recognized  by  their  oblong-oval  form, 
their  crenation  at  the  top,  their  glossy  surface,  their  transverse  and  lon- 
gitudinal nervures. 


ASTRINGENTS.  81 

The  whortleberry  (vaccinium  myrtillus,  L.),  of  the  family  of  the  erica- 
cere,  a  shrub  of  20  to  24  inches  in  height,  grows  in  France,  Germany, 
and  England;  with  green  and  angular  branches,  leaves  ovate,  dentate, 
very  glabrous,  resembling  those  of  the  myrtle;  calyx  adherent  to  the 
ovary,  limbus  free,  with  five  teeth  slightly  marked  or  absent;  corolla 
urceolate,  ten  included  stamens;  anthers  bifid  above  and  below,  having 
at  their  backs  two  erect  aristae;  the  fruit  is  a  globular  berry  crowned 
with  the  limbus  of  the  calyx,  with  five  polyspermatous  compartments; 
the  berries,  of  a  blackish  blue,  white  in  two  varieties,  are  refreshing  to  the 
taste.  They  are  used  to  make  a  syrup;  also  in  dyeing,  and  to  color  wines. 
They  Avere  formerly  praised  in  diarrhoea,  dysentery,  hasmoptysis,  catarrhal 
affections,  and  scorbutus.  M.  Reiss  now  uses  them  in  the  form  of  rob, 
tincture,  or  syrup,  for  diarrhoea,  in  which  he  has  found  them  of  use; -for 
these  berries  the  fruits  of  vaccinium  oxycoccus  might  be  substituted. 

Comfrey  (consolida  major,  Symphytum  officinale),  of  the  family  of  the 
Boraginacene,  does  not  really  differ  from  borage,  whose  emollient  proper- 
ties it  shares,  except  in  containing  a  very  slight  proportion  of  tannin;  it 
is  used  in  decoction,  as  a  ptisan,  and  in  syrup  for  chronic  diarrhoea  and 
hsemorrhage;  but  it  would  be  very  imprudent  to  expect  much  from  it. 

It  is  hard  to  understand  how  this  plant  obtained  such  a  reputation  that 
Paracelsus  stated  that  it  could  cure  fractures  without  apparatus  (Spren- 
gel:   "  Histoire  de  la  medecine,"  t.  III.,  p.  389). 

Catechu. 

This  is  a  remedy  of  great  value,  which  stands  by  the  side  of  rhatany 
and  tannin,  almost  all  of  whose  properties  it  shares.  Thus  it  may  be  sub- 
stituted for  them  with  advantage;  but  we  do  not  think  it  has  special  prop- 
erties. 

We  have,  however,  used  it  in  large  doses  in  the  treatment  of  tubercu- 
lous pulmonary  phthisis,  not  in  the  hope  of  curing  a  disease  which  is  so 
often  beyond  the  resources  of  art,  but  of  modifying  symptoms  which  are 
of  themselves  grave,  the  sweats,  cough,  expectoration,  diarrhoea. 

We  have  found  curious  results,  when  phthisical  patients  have  taken  it 
in  the  dose  of  from  1  to  G  grammes  (15  to  90  grains)  per  diem;  the  cough, 
fever  and  expectoration  diminished  notably;  the  diarrhoea  yielded  less  gen- 
erally, and  the  excessive  sweating  was  but  little  modified. 

Catechu  is  given  in  exactly  the  same  circumstances  as  rhatany  and 
tannin,  in  the  same  doses  as  the  former,  and  eight  or  ten  times  the  dose 
of  the  latter. 

Kino,  Dragon's  Blood. 

This  drug,  very  variable  in  origin,  and  consequently  in  composition, 
contains,  among  other  principles,  a  great  deal  of  tannin,  with  no  gallic  acid. 
Its  properties  are  all  due  to  the  tannin. 
6 


82  THERAPEUTICS. 

Fothergill,  who  introduced  it  into  the  matei'ia  medica  in  the  middle  of 
the  last  century,  advised  it  in  chronic  dysentery  and  diarrhcea,  in  immod- 
erate menstrual  discharge,  involuntary  seminal  losses,  diabetes,  and,  in 
general,  in  chronic  fluxes.  In  a  word,  it  is  used  where  tan,  tannin,  rhat- 
any,  etc.,  are  indicated;  but  it  is  much  less  active  than  the  two  latter  sub- 
stances. 

Dragon's  blood  must  be  placed  by  the  side  of  kino.  It  contains  much 
less  of  the  astringent  principles  than  gum  kino,  but  has  the  same  applica- 
tion.    They  are  rarely  used  externally. 

Rhatany. 

Therapeutical  action. — The  extract  of  rhatany  has  been  much  used  for 
severe  h:i?morrhages,  and  with  reason;  for  it  is  one  of  the  most  powerful 
haemostatics  that  we  possess.  We  do  not  mean  by  this  to  say  that  it  should 
be  preferred  to  other  non-astringent  haemostatics.  In  the  general  chapter 
on  astringent  medicine  we  shall  point  out  the  serious  inconveniences  of 
astringents,  and  will  show  that  they  ought  not,  in  general,  to  be  used  ex- 
cept in  moderation,  and  when  other  remedies  fail.  They  act  rapidly,  no 
doubt,  owing  to  the  rapid  modification  they  produce  in  the  crasis  of  the 
blood;  but  this  rapidity  and  this  modification  are  not  always  to  be  desired. 

Khatany  is  used  under  the  same  cii'cumstances  as  tannin;  in  chronic 
diarrh(Ka,  chronic  catarrh  of  the  lungs,  uterus,  vagina,  urethra,  etc. ;  top- 
ically, for  atonic  ulcers;  upon  relaxed  parts  such  as  the  inguinal  ring  in 
hernia;  in  n£evi  materni;  in  chronic  oedema. 

Ihssuvcs  of  the  anus. — In  this  complaint  rhatany  has  rendered  the  most 
signal  services. 

Boyer,  the  first  who  described  fissure  of  the  anus  well,  attributed  it 
chiefly  to  a  spasmodic  contraction  of  the  sphincter,  with  more  or  less  deep 
and  extended  crevasses.  The  latter  being  only  a  complication,  an  acces- 
sory to  the  disease,  it  was  only  necessary  to  relax  the  sphincter  by  cutting 
its  circular  fibres,  in  order  to  cause  immediate  cessation  of  the  spasmodic 
constriction  and  produce  cure. 

A  small  number  of  surgeons  share  at  present  the  view  of  Boyer  regard- 
ing the  slight  importance  of  the  fissure  and  the  preponderance  of  the  con- 
striction. Thus  two  opposed  parties  have  been  formed,  the  one  attend- 
ing  only  to  the  stricture,  and  neglecting  the  fissure,  while  the  other  re- 
garded the  stricture  as  caused  by  the  fissure,  and  likely  to  disappear  as 
soon  as  the  fissure  was  cured.  The  former  cut  the  fibres  of  the  anus  itself 
outside  of  the  fissure,  or  employed  relaxing  ointments,  containing  as  their 
chief  ingredient  the  poisonous  solanaceae;  the  latter  attacked  the  fissure, 
incising  it  so  as  to  convert  it  into  a  simple  wound  (which  is  not  easy  to 
comprehend),  and  applying  to  it  caustics,  catheretics,  various  pomades, 
analogous  to  those  employed  in  the  treatment  of  obstinate  sores  upon  other 
points.  Incision,  however,  has  prevailed,  upon  whatever  point  and  with 
whatever  intention  it  has  been  practised. 


ASTRINGENTS.  83 

Certainly,  when  we  see  physicians  occupied,  some  almost  exclusively, 
and  others  largely,  with  the  fact  of  the  spasmodic  stricture,  we  are  not 
tempted  to  inject  into  the  rectum  medicine  which  is  likely  to  exaggerate 
this  constriction,  such  as  rhatany.  This,  nevertheless,  is  what  M. 
Bretonneau  has  done,  and  upon  the  following  grounds: 

While  constipation  and  the  forcible  pressure  of  the  excrement  against 
the  sphincter,  distending  and  often  rupturing  it,  were  evidently  the  cause 
of  fissure  in  a  great  many  cases,  constipation,  on  the  other  hand,  continued 
to  be  the  greatest  obstacle  to  a  cure. 

Constipation  is  often  accompanied  by  a  very  remarkable  change  in 
the  lower  part  of  the  rectum:  immediately  above  the  sphincter,  the  rec- 
tum forms  an  amphoric  dilatation,  contracting  again  at  the  level  of  the 
sacro-vertebral  angle.  In  this  sac  the  faeces  accumulate  and  form  an  enor- 
mous bolus,  so  that  when  the  patient  goes  to  stool,  the  act  of  defecation 
is  almost  like  parturition, 

Bretonneau  thought  that  to  overcome  this  constipation,  whether 
accompanied  by  fissure  or  not,  it  was  proper  to  try  to  give  to  the 
lower  part  of  the  rectum  the  tone  which  was  wanting,  and  that 
rhatany  was  suitable  for  this  purpose.  He  gave,  in  simple  constipation 
accompanied  by  dilatation  of  the  rectum,  injections  of  extract  of 
rhatany  dissolved  in  water  with  the  addition  of  alcoholic  tincture  of 
rhatany. 

A  lady  treated  by  him  had,  with  this  form  of  constipation,  a  fissure 
of  the  anus  which  gave  herhori'ible  pain  and  greatly  impaired  her  health. 
He  gave  her  every  day  a  pint  of  rhatany  injection,  and  both  constipa- 
tion and  fissure  were  soon  cured.  In  other  cases,  where  constipation  co- 
existed with  spasmodic  contraction  of  the  anus  and  fissure,  the  same 
treatment  effected  complete  cures.  After  this,  he  determined  to  disre- 
gard the  fact  of  constipation  (for  it  is  sometimes  absent),  and  the  same 
success  crowned  his  attempts. 

His  first  step  was  taken  in  obedience  to  a  legitimate  induction;  these 
facts,  which  came  of  themselves,  aroused  his  attention;  he  had  only  to 
verify  them,  and  a  reasoned  course  of  experiments  led  him  to  a  treatment 
which  in  a  general  way  was  not,  perhaps,  rational,  but  which  is  success- 
ful; and  that  is  the  chief  thing. 

This  treatment  would  be  truly  reasonable  if  constipation  were  always 
a  cause  or  a  complication  of  the  fissure;  but  we  quite  often  see  patients 
who  have  fissures,  troubled  with  diarrhoea,  or  soft  stools,  or  habitually 
using  injectloiis  morning  and  evening  so  as  to  prevent  all  pressure  on 
the  sphincter;  and  yet  the  fissure  persists. 

Since  we  published  the  results  of  our  own  experiments  with  rhatany 
in  fissure,  many  physicians,  in  France  and  abroad,  have  tried  it;  in  Paris, 
the  surgeons  who  have  been  most  successful  with  it  are  Lisfranc  and 
Marjolin,  which  may  be  ascribed  both  to  the  good  judgment  of  these 
skilful  practitioners,  to  their  ready  acceptance  of  any  therapeutic  means 
which  could  save  a  bloody  operation,  and  also  to  their  fortunate  niodifica- 


84  •  THERAPEUTICS. 

tions  of  the  methods  of  application,  according  to  the  case,  the  obstinacy 
of  the  affection,  or  the  susceptibility  of  the  patient. 

Their  course  was  very  different  from  that  of  other  surgeons,  who,  per- 
haps too  ready  to  use  the  knife,  do  not  learn  to  handle  remedies  which 
act  less  rapidly  than  the  bistoury,  judge  too  severely  the  remedies  which 
they  do  not  wish  to  learn,  or  have  tried  without  perseverance,  and  even 
dare  to  regard  as  imaginary  certain  facts  which  they  might  easily  ascer- 
tain if  their  will  to  learn  had  been  a  right  will. 

It  remains  to  inquire  how,  and  by  what  mechanism,  rhatany  cures  fis- 
sure of  the  anus. 

The  answer  comes — "  It  cures,  and  what  matter  how  ?"  We  confess 
that  such  an  answer  is  often  authorized  in  therapeutics;  but  the  curious 
mind  wishes  to  know  why,  and  seeks  an  explanation  which  can  satisfy  it. 

Do  the  abundant  tannin  and  gallic  acid,  so  potent  as  astringents,  drive 
off  the  blood  which  accumulates  about  the  irritated  and  ulcerated  part,, 
and  does  the  cicatrix  form  rapidly  after  the  inflammatory  flexion  has  been 
dissipated  ? 

Or  does  the  excess  of  tonicity  imparted  by  the  remedy  to  the  muscles 
of  the  sphincter,  the  mucous  membrane  and  the  subjacent  cellular  net- 
work, enable  the  tissues  to  resist  more  vigorously  the  distention  caused 
by  the  bolus  of  excrement,  and  does  the  wound  which  is  kept  from  further 
daily  rupture  tend  spontaneously  to  cicatrize  ?  "We  ask  these  questions 
without  professing  to  solve  them. 

Must  we  say,  now,  that  rhatany  cures  fissure  by  some  special  virtue, 
as  cinchona  cures  fever,  as  mercury  and  iodine  cure  syphilis  ?  We  shall 
not  say  so;  it  is  probable  that  any  vegetable  substance  which  closely  re- 
sembles rhatany  in  chemical  composition  will  give  like  results.  And  in 
proof  of  this,  MM.  Payen  and  Manec  have  successfully  treated  some  cases 
of  fissure  of  the  anus  by  the  topical  application  of  monesia,  a  substance 
which,  among  other  principles,  contains  a  large  amount  of  tannin;  and 
further,  tannin  in  substance  has  given  the  most  happy  results. 

How  should  rhatany  be  used?  The  most  simple  method,  as  it  seems 
to  us,  is  the  following:  the  patient  takes  every  morning  an  injection  of 
bran-water  or  marshmallow-water  to  empty  the  intestine,  half  an  hour 
after  the  discharge  he  takes  an  injection  of  150  grammes  of  water  (5  oz.) 
with  from  4  to  10  grammes  of  extract  of  rhatany  (1  to  2^  drachms), 
to  which  are  added  4  grammes  of  tincture  of  rhatany.  The  injection  is 
held  only  an  instant,  and  is  repeated  at  night. 

In  many  cases  the  malady  is  obstinate,  and  no  resource  seems  to  be 
left  but  operation.  But,  with  certain  modifications  in  the  method,  and 
some  accessory  means,  an  unexpected  cure  is  sometimes  obtained. 

Experience  shows,  first,  that  rhatany  acts  in  an  entirely  local  manner 
upon  the  fissure.  We  have  cured,  by  simple  lotions  containing  the  ex- 
tract, some  very  painful  fissures,  which  became  external  when  the  patient 
strained  as  at  stool. 

If  the  fissure  is  deeper  and  obstinate,  rectal  injections  are  made  with 


ASTRINGENTS.  $5 

an  astringent  solution  by  a  syringe  that  gives  a  continued  stream,  while 
the  patient  resists  the  injection  which  he  throws  back  into  the  basin,  and 
which  may  be  used  over  and  over  again  for  three  or  four  minutes  at  a 
time,  or  longer. 

Constipation  very  often  forms  an  invincible  obstacle.  A  large  and 
hard  ball  of  fiBces'every  day  tears  the  fissure  and  destroys  the  commence- 
ment of  a  cicati'ix  formed  by  rhatany.  The  patient  must  then  take 
a  slight  laxative  every  day  during  the  treatment  and  even  for  some  time 
afterwards.  The  laxative  which  we  prefer  for  this  purpose  is  the  pow- 
dered belladonna  root,  taken  in  the  evening  in  a  dose  of  1 — 5  centigrammes 
(0*15 — 0'75  gr.).  In  our  article  on  belladonna  this  treatment  in  consti- 
pation is  especially  insisted  upon. 

Before  concluding,  we  ought  to  state  that  the  pains  are  often  singu- 
larly increased  during  the  first  few  days  of  treatment,  which  discourages 
both  patient  and  physician.  The  cause  is  easily  seen;  for,  whereas  the 
patient  used  to  go  to  stool  but  once  or  twice  a  week,  to  save  his  suffer- 
ings, he  now  goes  several  times  a  day,  which  gives  rise  to  pain  which  may 
sometimes  last  several  days  with  scarcely  an  intermission.  These  cases 
are  happily  rare;  when  they  occur,  but  one  injection  of  rhatany  per  diem 
should  be  given,  instead  of  two;  and  purgatives  must  not  be  given — at 
least,  not  until  the  susceptibility  of  the  intestine  is  diminished. 

When  the  pain  is  quite  abated,  only  the  rhatany  injection  is  given; 
and  at  the  close,  when  we  may  be  certain  that  the  cure  is  complete,  we 
order  one  to  be  taken  every  two  days  for  one,  two,  or  three  months. 

We  have  tried,  but  without  benefit,  in  treating  fissure,  suppositories 
composed  of  cacao  butter  5  grammes  (75  grains),  and  rhatany  1 — 2 
grammes  (15 — 30  gr.). 

Wicking  covered  with  ointment  containing  one  part  of  extract  of  rhat- 
any to  6  or  8  of  lard,  white  of  egg  or  cerate,  seems  to  us  advisable  in 
some  rare  cases. 

Every  one  will,  however,  modify  it  to  please  his  taste  and  to  suit  cir- 
cumstances. 

We  have  seen  a  certain  number  of  women  affected  with  old  and  deep 
fissures,  who  refused  to  undergo  the  bloody  operation,  but  recovered 
against  hope  after  using  rhatany  for  nearly  a  year. 

Fissicre  of  the  nipple. — It  was  natural  to  apply  to  this  complaint  the 
treatment  which  was  so  successful  in  anal  fissure;  and  M.  Blache  and 
we  have  done  this  with  success.  After  giving  suck,  the  tip  of  the  breast 
is  washed  each  time  with  a  very  strong  mixture  of  rhatany,  say  5  grammes 
of  extract  (75  gr.)  and  10  grammes  of  tincture  (  3  iiss.)  to  100  grammes 
of  water  (3xxv.);  a  little  of  a  sort  of  soft  paste  composed  of  white 
of  egg  and  extract  of  rhatany  is  also  left  in  the  bottom  of  the  fissure. 
The  breast  is  washed  when  the  child  is  to  suck  again.  Washes  contain- 
ing rhatany  are  also  very  useful  in  the  treatment  of  simple  excoriations 
of  the  nipple. 

Stomatitis. — In  mercurial  stomatitis,  in  certain  ulcerous  inflammations 


86  THERAPEUTICS. 

of  the  gums,  great  relief  is  obtained  by  holding  frequently  in  the  mouth 
a  wash  composed  of  10  grammes  (  3  iiss.)  of  the  extract,  30  grammes, 
(  3  viiss.)  of  the  tincture,  and  200  grammes  (  3  1.)  of  water. 

In  general,  rhatany  has  valuable  properties  in  relieving  the  pain  of 
ulcerative  disease  of  the  mucous  membranes;  and  as  to  the  skin,  it  re- 
lieves the  pain  with  wonderful  rapidity  when  applied  to  burns,  to  ulcers, 
and  more  especially  to  blisters,  when  painfully  inflamed  and  covered 
with  a  pultaceous  product. 

Tenesmus. — We  have  found  happy  results  in  treating  hsemorrhoidal 
and  dysenteric  tenesmus;  in  this  case  the  patient,  directly  after  each 
evacuation,  must  rise  from  the  seat,  resisting  the  effort  to  expel,  and 
wash  or  make  a  small  injection  at  once  with  a  decoction  of  8  grammes  of 
the  root  in  2  litres  of  water  (  3  i,  to  the  pint). 

Extract  of  rhatany  is  given  internally,  in  the  dose  of  50  centi- 
grammes to  4  grammes  per  day  (7'5 — 60  grains),  and  even  more.  The 
quantity  of  the  root  to  be  used  for  a  decoction  is  from  8  to  30  grammes, 

(3ij.— 3i)- 

For  external  use,  the  doses  are  nearly  unlimited. 

The  syrup  is  used  to  sweeten  ptisans,  in  proportions  as  desired. 


Paullinia,  or  GuakaisA. 

Paullinia  is  prescribed  in  powder,  extract,  or  syrup,  prepared  like  that 
of  rhatany. 

In  Brazil  and  the  neighboring  countries,  according  to  M.  Gavarelle, 
paullinia  is  often  used  by  the  natives  in  the  form  of  a  powder  mixed  with 
cacao,  and  made  into  a  ptisan.  It  is  remarkably  successful  in  the  diar- 
hcBas  and  dysenteries  so  frequent  and  severe  in  those  countries,  and  dur- 
ing convalescence  it  is  used  to  strengthen  the  stomach,  to  give  appetite, 
and  aid  digestion.  The  bitterness  of  the  ptisan  is  rather  agreeable  to 
most  tastes;  it  may  be  easily  corrected  with  sugar  or  any  sort  of  syrup. 

M.  Gavarelle  has  imported  it  from  Brazil,  and  finds  that  in  character 
it  resembles  rhatany,  but  that  its  bitterness  gives  it  some  advantage  over 
the  latter,  in  cases  of  dyspepsia  and  debility  of  the  digestive  organs. 

He  has  also  given  it  with  profit  in  the  various  fluxes,  where  the  astrin- 
gents are  so  successful,  as  diarrhoeas,  blennorrhagia,  hajmorrhage,  leucor- 
rhcea,  etc. 

We  have  of  late  often  given  the  powder  of  paullinia  in  diarrhoea,  and 
even  in  acute  or  subacute  dysentery,  and  have  been  able  to  prove  its  effi- 
cacy in  these  cases.  AVe  give  1  or  2  grammes  (gr.  15 — 30)  per  diem,  in 
divided  doses. 

Paullinia  has  lately  enjoyed  a  certain  popularity  in  Paris,  in  the 
treatment  of  migraine.  The  directions  which  accompany  the  drug  are 
as  follows:  if  the  attacks  come  several  times  in  a  month,  a  pill  of  10 
centigrammes  (1*5  gr.)  of  the  extract  must  be  taken  every  morning,  half 


ASTRINGENTS.  87 

an  hour  before  the  first  meal,  to  keep  off  the  attacks,  to  lessen  their  num- 
ber, and  with  the  hope  of  a  complete  cure.  If  one  is  warned  of  the  be- 
ginning of  an  attack,  50  centigranmaes  (7'5  gr.)  are  to  be  swallowed  at 
once,  of  powdered  paullinia  mixed  with  sweetened  water;  if  not,  it  is 
to  be  taken  during  the  attack.  If  there  is  no  improvement  in  a  quarter 
of  an  hour,  the  same  dose  is  to  be  repeated.  The  most  violent  migraine 
sometimes  disappears  in  five  or  ten  minutes,  and  quite  often  does  not  re- 
turn for  a  long  time. 

The  powder  alone,  taken  as  above  directed,  will  suffice  when  the  attacks 
are  infrequent  (once  a  month,  for  example),  and  are  not  complicated  with 
another  affection  which  renders  the  pills  absolutely  necessary. 

We  have  seen  paullinia  succeed  in  migraine,  but  we  must  add  that  its 
efficacy,  very  manifest  at  first,  diminishes  by  degrees,  and  most  patients 
grow  tired  of  it,  because  their  attacks,  while  less  painful,  usually  become 
longer  and  more  annoying. 

The  preparations  are  the  same  as  those  of  monesia  and  rhatany,  and 
are  given  in  the  same  manner  and  dose. 

As  paullinia  contains  cafeine,  its  action  is  perhaps  due  entirely  to  this 
substance,  which  may  well  be  substituted  for  it. 


Creasote. 

This  is  a  new  remedy,  discovered  by  Reichenbach,  a  chemist  of  Blausko, 
in  Moravia;  he  had  been  long  engaged  in  experiments  on  tar,  when,  per- 
ceiving that  the  epidermis  of  his  hands  dried  and  flaked  off,  he  found  that 
this  was  caused  by  a  special  substance  which  he  named  creasote. 

As  soon  as  this  remedy  was  introduced,  it  excited  a  great  emulation 
among  therapeutists,  each  seeking  to  find  new  virtues  in  it.  Cancer,  dar- 
tres, haemorrhages,  caries  of  the  bone,  scrofula,  phthisis,  were  cured  by 
creasote,  and  it  was  with  this  escort  that  it  was  introduced  to  France, 
about  1859.  There  Avas  an  unfortunate  infatuation  for  some  months,  dur- 
ing which  the  Institute  and  the  Academy  of  Medicine  were  assailed  by 
memoirs.  The  principal  ones  addressed  to  the  Academy  of  Medicine  were 
those  of  Caster,  Yvan,  and  d'Huc,  which  were  made  the  subject  of  a  very 
impartial  report  by  Martin  Solon  ("  Memoires  de  I'Academie  royale  de  me- 
decine,"  t.  V.,  p.  130),  who  made  numerous  trials  at  his  own  hospital.  Our 
statements  of  the  very  limited  therapeutic  virtues  of  creasote  are  based 
chiefly  on  this  report. 

Diseases  of  the  skin. — J^urns. — Burns  of  the  first,  second,  and  third 
degree  were  treated  by  water  with  -^^  part  of  creasote;  the  commission 
obtained  no  remarkable  result.  The  same  lotions  completely  failed  in  pem- 
phigus and  lepra  leontina.  Creasoted  pomade  containing  G — 30  drops  in 
30  grammes  (  3  i.)  of  lard,  employed  in  various  kinds  of  dartre,  was  of 
some  value  in  light  furfuraceous  varieties,  but  seemed  inefficacious  in 
the  severer  forms. 


88  THERAPEUTICS. 

Ulcers. — In  the  treatment  of  atonic  and  foul  ulcers,  with  callous  and, 
as  it  were,  bacony  edges,  benefit  has  been  obtained,  a  part  of  which  was 
due  to  care  in  dressing,  which  the  patients  had  not  previously  taken ;  nor 
did  creasote  possess  any  advantage  over  strips  of  diachylon,  leaves  of  lead, 
and  other  very  simple,  very  easy  and  well-known  applications,  which  do 
not  have  a  vile  odor.  So  objectionable  is  the  latter,  that  the  patient  has 
to  be  kept  at  home — and  even  then  he  infects  the  entire  house.  Creasote 
water  is  of  no  better  service  in  diseases  arising  from  a  prolonged  lying  in 
bed. 

Gangrene  of  the  mouth. — Dr.  Hasbach  claims  to  have  used  creasote 
with  success  in  this  disease,  which  is  observed  in  poor  children  living  in 
moist,  dirty  places;  it  is  spread  on  the  affected  places  with  a  brush;  a  line 
of  demarcation  soon  appears  between  the  sound  and  the  diseased  tissue, 
and  the  gangrened  portions  soon  separate  (  Union  medicale,  1853). 

Phlegmasios  of  the  mucous  membranes. — Injections  of  creasote-water 
have  succeeded  in  chronic  otorrhcea,  leucorrhoea,  and  blennorrhagia.  Dr. 
Arendt  lauds  it  highly  in  most  chronic  catarrhs,  and  especialh^  in  lientery 
and  chronic  diarrhoea;  in  this  case  he  orders  injections  in  the  dose  of  25 
drops  to  4  kilogrammes  (8^  lbs.)  of  water.  The  same  injections  have  ap- 
peared to  hiiii  to  be  useful  in  catarrh  of  the  bladder. 

Vomiting. — M.  Rayer  recommends  creasote  as  useful  for  stopping  the 
obstinate  vomiting  of  Briffht's  disease. 

IlcemorrJiage. — The  astringent  action  of  creasote  water  has  been  made 
useful  in  nose-bleed.  Pure  creasote  has  been  advised  in  large  arterial 
hjemorrhage,  but  Mignet  ("  Recherches  chimiques  sur  la  creosote,"  183-4) 
has  shown  that  even  that  from  small  arteries  is  not  arrested  by  creasote. 

Erectile  tumors. — Dr.  Thortsen,  of  Havelsberg,  has  spoken  highly  of 
its  value  in  the  treatment  of  naBvi  materni.  He  dilutes  the  creasote  more 
or  less  with  water,  according  to  circumstances,  and  applies  it  on  com- 
presses, renewed  twice  or  three  times  in  the  twenty-four  hours.  Under 
the  influence  of  this  treatment  the  mevus  at  first  excoriates,  then  ulcer- 
ates, and  at  last  wholly  disappears,  leaving  a  smooth  and  good-looking 
cicatrix. 

Caries  of  the  teeth. — Many  experiments  have  been  made  upon  this 
treatment  of  caries  {Bulletin  de  therap.,  1835,  t.  VIII.).  Evidently, 
this  substance,  like  those  which  are  a  little  catheretic,  has  a  general  calm- 
ing effect  on  toothache,  and  retards  caries,  just  as  do  nitrate  of  silver,  sul- 
phate of  copper,  etc.;  but  it  has  no  special  properties,  as  may  easily  be 
proved,  and  to-day  creasote  is  used  by  few  dentists. 

Phtliisis. — There  is  nothing,  from  pulmonary  phthisis  down,  Avhich  has 
not  been  professedly  cured  by  fumigations  of  creasote-water.  It  is  need- 
less to  say  that  catarrhs  are  sometimes  modified  by  this  method,  but  that 
phthisis  has  followed  its  fatal  course. 

Finally,  creasote  and  creasote-water  have  been  used  with  great  success 
to  preserve  anatomical  specimens;  and  it  must  be  considered  as  one  of 
the  most  sensitive  tests  for  albumin  in  the  urine. 


ASTKING  ENTS^  8  9 

Parasitic  diseases. — The  recent  experiments  on  fermentation  by  MM. 
Pasteur,  Beehamp,  Pouchet,  etc.,  having  proved  that  the  mucedines  are 
the  chief  agent  in  fermentations  and  putrefactions,  the  anti-ferments 
have  been  applied  in  parasitic  diseases.  This  idea,  which  has  given  rise 
to  a  whole  series  of  new  experiments,  will  be  studied  under  the  sulphites 
and  the  hyposulphites.  M.  Masse  has  used  creasote  upon  this  principle 
in  a  case  of  parasitic  pustular  sycosis.  A  mixture  of  alcohol  and  water 
in  equal  parts,  containing  1,  and  then  2  per  cent,  of  creasote,  has  caused 
the  pustular  eruption  and  the  parasites  to  disappear  in  two  weeks. 


Lead. 

Phthisis. — A  few  years  ago  Fouquier,  repeating  the  experiments  of 
Ettmiiller,  Pringle,  Amelungand  others,  recommended  the  neutral  acetate 
of  lead  internally  for  the  sweats  and  the  colliquative  diarrhoea  of  phthisis. 
He  succeeded  in  checking  the  diarrhoea,  but,  in  spite  of  what  he  has  said 
of  the  value  of  the  remedy  in  preventing  sweats,  we  have  scarcely  had  a 
single  success  in  the  many  attempts  we  have  made.  The  dose,  in  this 
case,  is  from  5  to  60  centigrammes  (0'75  to  9  grains)  in  the  24  hours. 
As  to  the  curative  action  of  acetate  of  lead  in  pulmonary  consumption, 
it  is  far  from  being  perfectly  demonstrated,  whatever  may  be  said  by  the 
numerous  authors  cited  in  Gmelin's  "  Apparatus  medicaminum."  It  ap- 
pears, however,  from  these  authorities,  that  we  cannot  wholly  deny  its 
possible  value  in  chronic  catarrhs  and  bronchorrhcea,  and  even  to  a  cer- 
tain extent  in  consumption. 

Certain  more  recent  experiments  deserve  a  place  here.  M.  Beau,  who 
was  very  probably  ignorant  of  the  labors  of  his  predecessors,  believing 
that  he  had  observed  that  pulmonary  phthisis  occurred  very  rarely  hi 
lead-workers,  thought  that  the  tuberculous  diathesis  might  be  combated 
by  the  use  of  lead.  For  this  purpose  he  tried  to  produce  a  kind  of  satur- 
nine intoxication,  taking  care  to  restrict  the  symptoms  within  limits  of 
easy  control.  He  gave  pills  containing  10  centigrammes  (gr.  I'o)  of 
ceruse,  and  by  a  rapid  progressive  increase  made  the  patient  take  six  or 
eight  a  day.  He  stopped  the  pills-or  lessened  the  dose  as  soon  as  arthral- 
gia appeared,  or  the  lead-line  on  the  gums,  or  analgesia,  or  the  icteroid 
complexion,  which  mark  the  first  stage  of  lead-poisoning. 

M.  Beau  cites  a  number  of  cases  in  which  under  the  influence  of  this 
treatment  he  saw  certain  symptoms  of  phthisis,  especially  cough  and  ex- 
pectoration, very  favorably  modified,  and  even  in  some  instances  the 
progress  of  the  disease  arrested;  but  he  brings  no  cases  of  complete  or 
final  cure.  He  assists  the  treatment  by  a  tonic  and  jjowerf  ully  reparative 
diet. 

In  imitation  of  M.  Beau,  Dr.  Funel  has  employed  the  acetate  (in  place 
of  the  carbonate)  of  lead,  and  reports  several  apparent  successes.  He  ex- 
plains the  method  of  action  by  supposing  that  the  salt  of  lead  is  absorbed 


90  THERAPEUTICS. 

and  carried  to  the  mucous  membrane,  where  it  acts  like  the  resins,  the 
balsams,  sulphur,  iodine,  etc.,  diminishing  the  secretion  from  the  mem- 
brane, whence  there  is  maintained  a  state  of  dryness  in  the  tubercles  or 
the  granulations  which  is  unfavorable  to  the  work  of  softening'  and  subse- 
quent breaking-down  of  the  morbid  products.  Thus,  in  the  author's 
opinion,  lead  exercises  no  direct  and  specific  influence  on  the  process  of 
tuberculization  itself,  either  in  workmen  or  in  the  patients  treated;  there 
is  no  real  immunity,  but  rather  an  opposition  (through  a  purely  local 
process)  to  the  evolution  of  the  tuberculous  products,  so  as  to  arrest  for 
a  variable  period  the  progress  of  the  disease  and  sometimes  to  bring 
about  a  true  cure. 

Our  intention  is  neither  to  discuss  this  interpretation,  nor  to  contest 
the  results  which  are  produced.  But  while  admitting  the  real  advantages 
which  it  possesses,  we  think  that  they  are  outweighed  by  the  serious 
objections  attached  to  lead-intoxication,  which  are  of  such  a  nature  that 
in  a  certain  number  of  the  cases  the  experiment  had  to  be  stopped  very 
soon.  We  therefore  think  that  there  is  scarcely  a  chance  that  this  treat- 
ment will  be  accepted  in  pulmonary  phthisis,  either  as  a  preventive  or  as 
a  cure.  Yet  it  is  possible  that,  if  managed  with  prudence  and  restricted 
to  certain  cases  with  exhausting  bronchorrhoea,  the  salts  of  lead  may 
be  of  good  service;  and  this  is  our  reason  for  here  making  mention  of 
them. 

Nervous  affections. — This  remedy  has  been  praised  in  epilepsy,  nym- 
phomania, etc.,  but  the  facts  are  so  few,  and  most  of  the  observations  so 
incomplete,  that  no  greater  value  can  be  assigned  to  it  than  to  so  many 
other  drugs  which  have  similar  reputations.  M.  Levrat-Perroton  reports 
fourteen  examples  of  the  success  of  neutral  acetate  of  lead  in  pills  of  'Zb 
milligrammes  (0"4  gr.)  and  of  the  subacetate  (12  drops  in  a  potion),  associ- 
ated with  various  antispasmodics,  in  neuroses  of  the  heart  and  hysteria; 
but  all  these  facts  need  criticism,  and  a  strict  diagnosis.  Its  utility  in 
superficial  neuralgias  is  a  better  ascertained  fact. 

We  must  not  omit  to  mention  the  internal  and  external  use  of  acetate 
of  lead  in  the  treatment  of  aneurism  of  the  heart  and  of  the  large  arteries. 
At  Paris,  Koreff  and  Dupuytren  popularized  the  method;  they  gave  enor- 
mous doses  of  the  neutral  acetate  intertially,  at  first  5  centigrammes  (gr. 
0*75),  in  the  morning,  and  rising  by  degrees  to  1,  2,  or  4  grammes  (  3  i.) 
Y>ev  diem,  while  the  region  of  the  heart  or  the  aneurism  was  kept  con- 
stantly covered  with  compresses  wet  with  Goulard's  lotion.  They  assisted 
the  treatment  by  bloodletting,  diet,  and  rest.  This  method  was  pointed 
out  long  before  them;  it  has  certainly  had  success,  and  deserves  to  be  em- 
ployed more  than  it  is.  If  we  recall  the  physiological  action  of  lead,  whicli 
certainly  makes  the  circulation  slower  and  the  pulse  smaller,  while  it  per- 
haps diminishes  the  calibre  of  the  vessels,  we  shall  see  that  it  ought  to  be 
of  use  in  the  diseases  of  the  circulatory  centre  and  the  arteries. 

We  must  add  that  the  method  has  lately  been  adopted  by  Brachet,  of 
Lyons,  who  associates  digitalis  with  the  acetate  of  lead,  in  order  to  add  to 


ASTRINGENTS.  91 

the  chances  of  success  in  hypertrophy  of  the  heart.  His  formula  is  the 
following:  Acetate  of  lead,  2  grammes  (30  grs.);  extract  of  digitalis,  1 
o-ramme  (15  grs.);  make  20  pills.  He  gave  at  first  two  pills  a  day,  increas- 
ino-  bv  one  pill  every  five  days  until  the  amount  taken  was  2  pills  morn- 
ino-  and  evening.  In  confirmed  aneurisms  or  entirely  organic  hypertro- 
phies, he  usually  obtained  only  a  temporary  amendment;  while,  in  the  case 
of  recent  or  not  advanced  hypertrophy,  the  effects  seemed  to  him  unques- 
tionable. 

These  facts,  presented  by  M.  Brachet  to  the  Academy,  have  met  with 
contradiction  from  several  sources.  We  will  quote  among  others  M.  Robert, 
who,  having  seen  acetate  of  lead  generally  fail  in  true  hypertrophy,  was 
led  to  consider  the  facts  reported  by  M.  Brachet  as  cases  of  simple  neuro- 
sis of  the  heart,  and,  in  consequence,  to  attribute  the  good  effects  of  the 
treatment  to  its  sedative  action  on  this  organ.  However,  we  must  add 
that  quite  lately.  Dr.  Valentin,  of  Vitry-le-Fran9ois,  has  repeated  the  ex- 
periments of  M.  Brachet,  with  the  same  formula,  and  has  obtained  good 
results  in  certain  affections  which  present  the  signs  of  an  early  period  of 
cardiac  hypertrophy.  According  to  this  author,  acetate  of  lead,  taken  in- 
ternally, acts  on  the  circulatory  centre  as  it  does  on  the  arterial  tubes  in 
peripheral  aneurisms  which  are  accessible  to  local  applications,  that  is,  by 
its  astringency,  which  assists  the  contraction  and  the  crispation  of  the  car- 
diac capillaries,  and  thus  favors  the  absorption  of  hypertrophic  molecules. 
Although  the  great  part  of  the  facts  reported  by  M.  Brachet  or  M.  Val- 
entin in  favor  of  the  treatment  may  be  questioned,  and  the  results  are  far 
from  decisive,  we  still  think  them  quite  sufficient  to  invite  new  experiments, 
and  to  authorize  hopes  of  success,  as  far,  at  least,  as  a  naturally  grave  and 
obstinate  affection  like  hypertrophy  of  the  heart  can  admit  of  it. 

Suh-acetate  of  lead. — This  salt,  known  by  the  name  of  extract  of  Sat- 
urn, liquid  acetate  of  lead,  vinegar  of  Saturn,  eau  de  Saturne,  eau  de  Gou- 
lard, is  decomposed  by  undistilled  water  into  acetate  of  potassium,  calcium, 
or  sodium,  and  sulphate,  chloride,  carbonate,  and  phosphate  of  lead,  which 
are  precipitated  in  the  liquor  and  make  it  milky,  in  which  state  it  is  known 
by  the  names  of  eau  vegeto-minerale,  eau  de  Goulard. 

The  white  water,  or  eau  de  Saturne,  differs  from  eau  de  Goulard  in 
not  containing  alcohol;  yet  they  are  very  often  confounded. 

It  is  under  these  forms  that  the  subacetate  of  lead  is  ordinarily 
employed;  for  it  is  seldom  used  pure.  This  is  one  of  the  best-known 
astringents.  Placed  in  contact  with  the  skin  or  an  ulcer,  eau  de  Goulard 
expels  the  blood,  shrinks  it,  hardens  it,  shrivels  it — in  a  word,  drives  the 
liquids  from  the  tissues.  This  powerful  astringent  action  is  not  accom- 
panied by  pain;  and  pain,  if  there  be  any  present,  is  usually  quieted. 

Diseases  of  the  skhi. — In  burns  of  the  first  degree,  and  when  suppu- 
ration has  occurred,  Goulard's  water  is  applied  to  the  affected  parts  by 
compresses  kept  constantly  wet.  The  same  method  is  used  in  dartres,  of 
the  acute  character  only,  as  eczema  simplex  and  certain  forms  of  herpes; 
in  chronic  prurlginous  cutaneous  affections,  such  as  eczema  chronicum;  m 


92  THEEAPEUTICS. 

ulcers  of  the  legs,  especially  if  they  tend  to  bleed,  or  if  the  edges  become 
cedematous  and  torn. 

The  sweat  of  the  feet  is  sometimes  so  acrid  as  to  attack  the  skin  be- 
tween the  toes;  this  causes  a  foul-smelling  exudation,  and  what  is  more 
important,  an  ulcerous  surface,  Avhich  by  its  extreme  sensibility  impedes 
walking  and  prevents  laborers  from  working.  To  cure  this,  introduce 
between  the  toes  a  few  drojDS  of  the  folloAving  compound: 

Red  oxide  of  lead    1  gramme  (15  grains). 

Liquid  subacetate  of  lead 29  grammes  (435  gn). 

This  application,  made  once  a  week,  will  cure  the  affection  and  pre- 
vent its  relapse. 

The  author,  M.  A.  Gaffard,  of  Aurillac,  says  that  this  liquid  only  mod- 
erates the  persj^iration  Avithout  entirely  suppressing  it;  it  makes  it  inod- 
orous, and  the  skin  regains  its  former  thickness  without  losing  its  sup- 
pleness. We  accept  the  method,  but  it  requires  prudence  and  watchful- 
ness in  use,  for  the  sudden  suppression  of  a  local  transpiration,  if  old,  and 
of  the  nature  of  an  emunctory,  may  have  grave  consequences  for  the  gen- 
eral health. 

Diseases  of  the  inucous  menibranes. — In  collyria,  the  eau  de  Goulard 
is  used  for  catarrhal  scrofulous  ophthalmia;  in  injections  in  the  nasal 
fossa?,  for  chronic  coryza,  oza;na,  in  the  auditory  meatus,  for  otorrhoea, 
in  the  vagina  or  urethra,  for  leucorrhoea  and  blennorrhagia,  in  the  rec- 
tum for  proctorrhoea,  purulent  ha?morrhoidal  flux,  the  chronic  diarrhoea 
which  follows  dysenteries,  and  is  due  to  ulceration  of  the  lower  parts  of 
the  large  intestine;  in  gargles,  in  catarrhal  angina,  oedema  of  the  uvula, 
aphthous  stomatitis. 

An  application  of  this  remedy  Avas  made  some  years  ago  by  Dr.  Bar- 
thez,  then  chief  physician  of  the  military  hosj^ital  of  Saint  Denis.  There 
were  cases  not  only  of  chronic  dysentery,  but  of  the  acute.  The  fol- 
lowing account  is  borrowed  from  the  Gazette  des  hopitaux  (dccembre, 
1845)- 

"  Since  August,  M.  Barthez  has  had  the  care  of  a  large  number  of 
cases  of  dysentery,  several  of  which  died  in  spite  of  the  usual  treatment. 
Seeing  the  want  of  success,  he  resorted  to  the  subacetate  of  lead.  Pro- 
ceeding with  the  caution  which  such  a  drug  requires,  he  reached  the  dose 
(by  injection)  of  100  drops  of  extract  of  Saturn,  or  5  grammes,  in  500 
grammes  of  tepid  water,  without  causing  injury.  The  dysentery  was 
checked  almost  instantly. 

"One  condition  is  essential  to  success:  the  remedy  must  be  applied 
at  the  beginning  of  the  disease.  Later,  the  rectum  is  so  irritated  that  the 
injection  cannot  be  retained." 

More  recently  M.  Barthez  has  read  a  fresh  paper  on  the  same  subject, 
to  the  Societe  des  medecins  des  hopitaux  de  Paris.  He  has  reached  the 
enormous  dose  of  30,  40,  100  grammes  (  3  viiss.,   3  x.,   3  xxv.)  in  injec- 


ASTKINGENTS.  93 

tion,  without  producing  symptoms  of  poisoning'.  These  results  have  been 
confirmed  by  further  experiments  of  M.  Boudin's,  made  while  chief  phy- 
sician to  the  Hopital  militaire  du  Roule. 

The  subacetate  of  lead  has  been  used  by  him  in  injections  in  550  or 
600  cases  of  diarrhoea,  dysentery,  or  epidemic  cholera.  The  medicine,  dis- 
solved in  100  grammes  (  3  xxv.)  of  distilled  water,  was  given  in  amounts 
of  from  ten  to  sixty  grammes  (  3  iiss. —  3  xv.)  in  the  24  hours,  in  several 
injections  of  a  pint  each.  Not  only  was  the  remedy  as  thus  used  com- 
pletely harmless,  but  the  success  was  most  satisfactory. 

Encouraged  by  this  immunity,  M.  Boudin  gave  the  same  pure,  that 
is,  without  any  addition,  by  the  mouth,  for  the  obstinate  vomiting  in  six 
or  eight  cases  of  cholera,  which  resisted  all  ordinary  remedies.  No  in- 
jury whatever  followed,  and  in  several  cases  relief  was  given.  He  thinks 
that,  if  used  in  small  doses,  the  subacetate  might  not  perhaps  be  so  in- 
nocent, as  it  might  be  more  easily  absorbed. 

There  are  circumstances  requiring  a  still  larger  dose.  M.  Somme,  of 
Antwerp,  has  shown  that  the  solution  of  subacetate  is  one  of  the  best 
remedies  for  mercurial  salivation,  provided  a  sufficient  dose  of  the  salt  be 
dissolved  in  the  water.  He  made  gargles  and  washes  with  the  enormous 
proportion  of  one-eighth  or  one-sixth  part  of  extrait  de  Saturne;  and  M. 
Ricord  has  lately  shown  that  the  blennorrhagiie  and  blennorrhagic  ulcer- 
ations of  the  neck  of  the  uterus  required,  in  order  to  recover  rapidly  and 
thoroughly,  the  introduction  of  a  tampon  into  the  vagina,  in  contact  with 
the  OS  tincae,  soaked  in  a  solution  resembling  that  which  M.  Somme  used 
in  mercurial  salivation. 

Gargles  of  acetate  of  lead  have  one  objection  which  usually  disgusts 
the  patient;  the  teeth  become  of  a  horrible  black,  which  disappears  after 
the  treatment  more  or  less  completely,  but  gives  to  the  mouth  a  repulsive 
look  for  some  days. 

Jlceynorrhages. — The  eau  blanche  and  the  extract  of  Saturn,  in  a  pure 
state,  would  not  probably  arrest  the  bleeding  of  a  large  artery  or  vein; 
but  they  are  among  the  most  effectual  means  for  checking  the  haemor- 
rhages from  granulations  and  capillaries  following  great  operations,  those 
which  occur  on  the  surface  of  cancerous  wounds  or  fungous  ulcers,  and 
exudations  of  blood  from  the  mucous  membranes  of  the  nose  and  uterus, 
etc. 

It  remains  to  speak  of  the  use  of  subacetate  of  lead  in  preparing 
moxas.  The  idea  is  Marmorat's  (Journ.  des  connais.  vied.-cJdr.,  t.  H., 
p.  172).  The  way  to  the  discovery  was  doubtless  suggested  by  Cadet 
and  Rathelot,  who  had  advised  the  dipping  of  matches  for  artillery  and 
for  fireworks  in  a  solution  of  concentrated  neutral  acetate  of  lead  [Bull. 
de  2>harm-,  t.  IV.,  p.  419).  "  The  moxa,  which  is  made  of  paper  pre- 
viously dipped  in  extract  of  Saturn  and  dried,  is  the  easiest  to  prepare, 
the  most  convenient  to  use,  the  most  regular  in  action,  and  the  easiest  to 
regulate,"  says  Marmorat.  "  I  call  it  the  moxa-paper;  it  must  have  lit- 
tle or  no  size;  it  then  takes  fire  at  the  tinder-box  and  burns  like  tinder. 


94  THEKAPEUTTCS. 

It  is  kept  in  a  portfolio,  and  a  few  seconds  suffice  to  prepare  a  moxa,  by 
cutting  a  strip  of  a  few  lines  in  width,  which  is  rolled  up  into  a  cylinder 
of  any  desired  size.  The  combustion  is  slow  or  fast,  according*  as  it  is 
rolled  tight  or  loose," 

Ingrowing  nail. — Many  local  remedies  have  been  tried  in  vain  for 
this  affection,  and  surgeons  have  been  forced  to  perform  operations  which 
almost  always  consist  in  the  removal  of  the  fungous  cushion  and  a  part 
or  the  whole  of  the  nail.  It  is  our  duty  then  to  make  known  an  extremely 
simple  process,  which  we  have  always  found  to  succeed,  consisting  simply 
in  softening  between  the  fingers  a  piece  of  emplastrum  cerussa?  (carbon- 
ate of  lead  plaster),  and  introducing  it  beneath  the  fungous  cushion.  The 
flesh  is  dry  the  next  day,  less  red,  less  swollen  and  painful;  it  soon  atro- 
phies, and  the  cure  is  finished  in  a  few  days. 


Alum. 

Alum  as  a  topical  agent. — The  primarx''  effect  of  alum  suggested  the 
uses  to  which  it  might  be  put;  and  as  the  presence  of  blood  in  the  tis- 
sues was  the  most  salient  phenomenon  in  hcemorrhage,  inflammation,  and 
the  various  fluxes,  alum  was  first  used  in  these  three  classes  of  disease. 

Hcernorrhage. — In  young  people  at  the  period  of  puberty,  in  chil- 
dren during  whooping-cough,  or  after  excessive  loss  of  blood,  nose-bleed 
occurs,  which  is  often  followed  by  immediate  and  severe  symptoms,  or  is 
the  cause  of  obstinate  maladies  such  as  amenorrhoea,  chlorosis,  and  vari- 
ous neuroses.  When  the  flow  of  blood  does  not  stop  soon,  it  may  be 
checked  by  snuffing  up  alum-water;  if  this  is  not  sufficient,  we  order  25 
or  30  centigrammes  (gr.  3 '8 — 4'6)  of  alum,  finely  powdered  like  snuff  or 
moulding  plaster,  to  be  used  several  times  a  day;  this  usually  makes 
plugging  unnecessary,  though  it  may  be  combined  with  it.  This  topical 
treatment  does  not  prevent  the  internal  use  of  cinchona,  so  efficacious  in 
this  form  of  haMnorrhage.  Alum  is  especially  valuable  for  arresting 
uterine  haemorrhage  after  childbirth.  Riviere  injected  it  into  the  uterus 
and  vagina,  dissolved  in  an  astringent  decoction  ("  Opera  omn.").  Leake 
dissolved  it  in  water  and  used  it  in  the  same  way  ("  Practical  Observa- 
tions, etc.").  Smellie  soaked  a  sponge  in  a  strong  solution,  and  passed 
it  up  the  vagina  ("  Collection  of  Praeternatural  Cases").  Fabricius  Hil- 
danus  sprinkled  a  tampon  with  alum  and  then  introduced  it  as  far  as 
possible  ("  Epistolarum  centuri^").  Such  means  are  most  successful 
when  the  bleeding  occurs  subsequent  to  parturition  or  during  lactation, 
at  the  period  of  weaning  or  toward  the  critical  age;  they  will  act  only 
temporarily  when  the  cause  is  the  implantation  of  the  placenta  over  the 
neck  of  the  uterus,  a  polypus  in  the  cavity  of  the  womb,  or  the  softening 
of  a  cancerous  tumor. 

Excessive  hajmorrhoidal  bleeding  must  be  combated  in  the  same  way, 
as  also  the  bleeding  which  often  follows  the  excision  of  piles.     We  may 


ASTKINGENTS.  95 

imitate  Paulus  Aegineta,  and  give  several  injections  of  alum;  or  Helve- 
tius,  who  made  a  suppository  with  alum  and  placed  it  in  the  rectum.  As 
regards  htematuria,  it  is  seldom  arrested  by  aluminous  injections,  as  the 
blood  rarely  comes  from  the  surface  of  the  vesical  mucous  membrane,  but 
is  most  commonly  due  to  grave  renal  lesions,  or  the  passage  of  a  calcu- 
lus into  the  pelvis  and  the  ureters,  or  the  existence  of  a  cancer  of  the 
bladder. 

Alum  is  very  successful  in  checking  traumatic  haemorrhage,  but  only 
when  small  vessels  are  open.  When,  after  a  severe  operation,  the  blood 
continues  to  soak  the  dressings,  and  the  bleeding  threatens  life,  it  has 
been  recommended  to  sprinkle  alum,  and  to  soak  the  charpie  next  to  the 
cut  with  alum-water.  In  cachectic  children,  or  those  who  have  already 
lost  blood,  a  leech-bite  will  sometimes  continue  to  bleed;  and  such  a 
slight  cause  may  produce  death,  as  we  have  unfortunately  too  frequent 
occasion  to  know.  Before  using  the  serre-fines,  the  suture,  cauterization, 
or  compression,  which  is  often  impracticable,  the  little  wound  and  the 
parts  around  it  should  be  covered  with  powdered  alum;  or  little  nails  or 
cones,  after  the  advice  of  Borelli  and  Diemerbroeck,  may  be  made,  and 
the  points  introduced  into  the  bite,  and  kept  there  by  the  finger  or  a 
bandage.  This  simple  method  will  succeed  perfectly  in  arresting  the 
severe  haemorrhages  which  so  often  follow  the  extraction  of  teeth. 

Bleeding  from  the  gums  and  pharynx  is  daily  relieved  by  gargles  of 
alum. 

This  topical  treatment  has  also  been  advised  in  hiematemesis  and 
melfena.  We  can  understand  its  value  in  case  the  blood  exhales  from 
the  surface  of  the  mucous  membrane  or  from  superficial  ulceration  of  the 
stomach  or  intestine;  but  when  due,  as  is  usually  the  case,  to  a  radical 
degeneracy  of  tissue,  it  is  very  certain  that  no  use  of  alum  can  do  more 
than  retard  the  inevitable  ending  of  all  this  class  of  diseases,  while  even 
the  suppression  of  htcmorrhage  will  rarely  be  effected. 

Local  use  of  alum  in  inflammations. — Whenever  an  inflammation  is 
restricted  to  a  very  limited  part  of  the  body,  and  is  accompanied  by  small 
general  disturbance,  it  may  be  treated  by  repercussives,  that  is,  by  reme- 
dies which  drive  the  blood  from  the  vessels  in  almost  a  mechanical  way. 
Alum  has  always  been  useful  in  slight  ophthalmia  and  superficial  inflam- 
mation of  the  buccal  membrane.  Saint-Yves  often  used  it  for  pterygium 
and  the  films  which  succeed  variola,  or  remain  after  the  cicatrization  of 
corneal  ulcers  ("  Nouveau  traite  des  maladies  des  yeux,"  p.  150).  lie 
mixed  calcined  alum  with  sugar  and  phosphate  of  lime,  and  blew  the 
powder  into  the  eyes.  Lindt  used  the  same  remedy  to  cure  chemosis. 
A  simple  solution  of  alum  is  equally  effective.  Riviere  considers  gargles 
and  insufflations  of  alum  excellent  in  elongation  of  the  uvula  and  chronic 
swelling  of  the  tonsils  ("  Op.  omn.  med.  prax.,"  liv.  VI.,  p.  93).  The 
same  author,  following  Dioscorides  and  Paulus  Aegineta,  regards  the 
treatment  as  very  effective  in  ulceration  and  swelling  of  the  gums, 

Aretaeus,  Celsus,  Paulus  ^Egineta,  and  all  their  successors,  agree  as 


96  THERAPEUTICS. 

to  the  virtues  of  alum  in  catarrhal  angina,  and  even  non-suppurative  ton- 
sillitis. We  have  often  been  pleased  with  the  results.  Almost  all  the 
authors  we  have  cited  consider  it  very  potent  in  aphthse  and  aphthous 
angina. 

Before  Bretonneau  wrote  on  the  special  inflammations  of  the  mucous 
tissue  (Paris,  182G),  the  nature  of  the  malady  called  malignant  or  gangre- 
nous angina  was  extremely  obscure;  but,  since  that  publication,  the  treat- 
ment may  be  easily  appreciated,  and  in  some  degree  classified,  and  the  ex- 
perience of  our  predecessors  may  be  turned  to  our  advantage. 

M.  Bretonneau  learnt  from  Aretteus  that  in  pharyngeal  diphtheria  gar- 
gles and  insufflations  of  alum  arrested  the  development  and  extension  of 
false  membrane  in  the  air-passages,  and  consequently  prevented  croup. 
He  was  more  successful  than  he  hoped  with  this  medicine;  and  we,  in 
1828,  having  been  placed  on  a  special  commission  to  several  departments 
where  an  epidemic  of  diphtheria  was  raging,  were  convinced  of  the  ex- 
treme efficacy  of  alum.  When  this  disease  is  limited  to  the  gums,  and 
forms  a  disease  known  in  the  country  as  chancre,  a  wash  of  alum  dissolved 
in  water  with  vinegar  and  honey  stops  the  disorder,  which  had  in  some 
cases  resisted  the  most  various  and  energetic  treatment  for  months.  When 
developed  on  the  tonsils,  "we  may  limit  ourselves  to  simple  gargles,  if  the 
patient  is  an  adult  and  we  can  depend  on  his  exactitude;  but  it  is  more 
prudent  to  insufflate  powdered  alum.  In  the  country  we  commonly  used 
the  spindle  of  a  spinning-wheel,  a  piece  of  elder  with  the  pith  removed, 
or  a  piece  of  reed,  and  instructed  the  pai'ents  in  the  process,  which  they 
usually  performed  with  great  ease.  We  loaded  one  end  of  the  tube  with 
4  grammes  (  3  i-)  of  powdered  alum,  then  applied  the  tongue  to  that  end, 
and,  suddenly  removing  the  tongue,  blew  briskly  through  the  tube,  thus 
sending  a  large  quantity  of  the  powder  all  over  the  back  part  of  the  mouth, 
the  entrance  of  the  larynx,  of  the  oesophagus,  and  the  nasal  fossa^.  The 
patient's  cries  and  agitation  were  very  useful,  and  in  making  the  insuffla- 
tion we  chose  the  moment  when  he  was  making  a  deep  inspiration.  This 
operation  is  to  be  repeated  five,  six,  or  eight  times  a  day,  and  is  visually 
followed  by  efforts  to  vomit  and  abundant  salivation,  but  after  a  quarter 
of  an  hour  all  is  calm;  and  the  severest  diphtheria  often  yields  in  a  few 
days,  if  it  has  not  attacked  the  interior  of  the  larynx.  When  the  skin, 
the  nipple,  or  the  genital  mucous  membranes  are  attacked,  as  is  very  com- 
mon in  epidemics  (see  our  "  Memoire  on  cutaneous  diphtheria:  Archives 
generales  de  medecine,"  t.  XXII.,  p.  383),  frequent  washings  with  alum- 
water  cure  this  inflammation,  not  without  difficulty. 

The  same  remedy  is  recommended  for  aphthce  of  the  mouth  and  larynx, 
muguet,  and  pultaceous  angina  and  stomatitis.  We  have  often  used  it 
with  great  success  in  scarlatinous  angina,  unless  the  latter  persisted  after 
the  cutaneous  exanthema  had  entirely  disappeared. 

Alum  is  also  of  use  in  women,  and  especially  in  very  young  girls,  for 
certain  acute  phlegmasia?  of  the  vulva  which  sometimes  are  epidemic,  es- 
pecially among  the  lower  classes,  and  are  accompanied  by  puriform  dis- 


ASTRINGENTS.  97 

charges  or  membranoid  exudations.  We  know  how  important  it  is  to 
relieve  these  vulvar  irritations  quickly,  which  in  little  girls  are  so  often 
the  cause  of  had  habits.  Alum,  however,  useful  as  it  is,  has  not  the  value 
of  nitrate  of  silver,  which  often  cures  at  once  the  disease  and  the  vice. 

For  vulvar  vegetations,  if  not  voluminous,  alum  is  truly  successful;  it 
is  used  in  powder,  frequently  renewed.  In  inflammation  of  the  mucous 
membrane  of  the  vagina,  and  blennorrhagia,  aluminous  injections  form  one 
of  the  best  adjuvants  of  nitrate  of  silver.  In  fine,  an  alum-wash  is  useful 
for  relieving  the  unendurable  itching  about  the  external  parts  of  genera- 
tion to  which  women  are  so  subject;  we  prefer,  however,  in  this  case,  car- 
bonate of  potassium  or  sodium,  and  corrosive  sublimate. 

Alum  is  very  useful  in  many  disorders  of  the  female  organs  of  genera- 
tion, when  it  should  be  used  in  solution,  or,  better,  in  powder.  For  super- 
ficial ulcers  and  granulations  of  the  neck  of  the  womb,  a  small  plug  of 
cotton  is  made,  inside  of  which  is  put  a  little  powdered  alum,  and  the  plug 
is  placed  directly  against  the  neck  of  the  womb.  A  thread  serves  to  with- 
draw it.  Or,  the  powder  may  be  blown  upon  the  neck  of  the  womb  or  the 
inner  surface  of  the  vagina,  by  means  of  a  speculum. 

If  we  wish  to  cause  the  remedy  to  reach  the  interior  of  the  neck  in 
leucorrhcea  resulting  from  morbid  secretion  of  the  follicles,  wicking  cov- 
ered with  alum-powder  may  be  introduced,  or  a  crystal  shaped  with  the 
knife. 

The  tampon  containing  the  powder  may  be  useful  in  cases  of  prolapse 
of  the  womb  due  to  relaxation  of  the  vagina,  which  is  so  common  after 
partui'ition  or  chronic  leucorrhcea. 

A  dentist  of  Paris,  M.  Lefoulon,  who  had  gained  a  great  reputation 
for  treating  painful  caries  of  the  teeth,  has  published  his  method.  He 
makes  a  soft  paste  with  alum,  sulphuric  ether,  and  a  little  mucilage  of  gum- 
arabic,  and  fills  the  cavity  of  the  tooth  with  it.  The  filling  is  done  twice 
a  day  while  there  is  pain ;  then  once  a  day  for  two  or  three  weeks,  until 
the  dental  nerve  is  no  longer  sensitive.  Then  the  tooth  may  be  filled,  or 
the  paste  may  be  used  once  a  week  or  fortnight. 

Bennati  {B^dletin  general  de  therapeutique,  t.  I.,  p.  265)  has  shown 
the  usefulness  of  alum-gargles  in  some  cases  of  aphonia,  and  in  great  al- 
terations of  the  timbre  of  the  voice.  The  patient  has  at  the  same  time  to 
practise  certain  vocal  exercises,  to  which  great  importance  is  attached. 

It  is  easy  to  understand  how  M.  Payan,  of  Aix,  cured  a  deafness,  as- 
sociated with  chronic  tonsillitis,  by  repeated  applications  of  alum  to  the 
tonsils.     We,  and  many  others,  have  used  nitrate  of  silver  in  the  like  case. 

Alum  is  often  used  to  check  fungous  granulations;  it  is  then  sufficient 
to  use  it  in  solution;  but,  if  a  strong  astringent  action  is  wished  for,  and 
there  are  somewhat  hard  excrescences,  syphilitic  or  otherwise,  alum  in 
powder,  especially  if  burnt,  is  preferred. 

Ingrowing  oiail. — Dr.  Somme,  of  Antwerp,  has  proposed  burnt  alum  in 
this  aifection,  without  any  previous  operation.  With  a  flat  stylet  the  alum 
is  pushed  between  the  flesh  and  the  nail  as  deep  as  possible.  A  crust  forms, 
7 


98  THERAPEUTICS. 

which  is  to  be  removed  carefully,  twice  a  day  at  first,  afterwards  once  a 
day.  If  the  crust  were  left,  the  purulent  matter  would  remain  enclosed 
by  it,  and  no  benefit  would  result.  The  remedy  is  very  simple  and  easy, 
but  requires  a  great  deal  of  care  and  perseverance  {An7i,  de  la  Soc.  de 
medecine  d^Anvers). 

Chilblains. — Added  to  the  white  of  egg  and  camphorated  brandy, 
alum  forms  a  liniment  which  strengthens  the  skin  against  chilblains  and 
the  effects  of  prolonged  stay  in  bed  (Merat  et  Delens:  "  Diet.  univ.  de 
mat.  med.,"  t.  I.,  p.  209). 

The  topical  action  of  this  substance  has  been  recommended  in  certain 
fluxes;  thus,  aluminous  washes  are  very  good  in  mercurial  salivation, 
and  in  salivation  due  to  inflammation  of  the  buccal  mucous  membrane; 
but,  as  Gmelin  ("  Apparatus  med.,"  t.  I.,  p.  121)  remarks,  there  is  great 
danger  in  suppressing  with  alum  the  discharge  of  old  ulcers  or  excessive 
local  fetid  sweats.  The  same  remark  applies  to  local  treatment  in  leu- 
corrhcea. 

This  danger  does  not  exist  when  alum  is  to  be  used  in  obstinate  diar- 
rhoea, or  glairy  vomiting,  and  certain  other  symptoms  due  to  a  chronic 
phlegmasia  of  the  mucous  membrane  of  the  digestive  tract.  In  this  case, 
following  the  advice  of  Paulus  Aegineta,  Zacutus,  Bisset,  some  evacu- 
ants  are  given  before  alum  is  used.  We  have  seen  Recamier,  neglect- 
ing this  advice,  succeed  in  quieting  very  obstinate  vomiting  and  diarrhoea 
by  adding  to  the  alum  a  small  proportion  of  opium;  and  MM.  Fouquier 
and  Barthez  claim  that  in  dothinenteritis  (putrid  fever)  they  successfully 
used  alum  to  check  the  ulceration  of  the  follicles  and  aid  in  their  cicatri- 
zation, to  arrest  haemorrhage  and  diarrhcea,  and  to  aid  digestion  in  con- 
valescence. The  amount  given  by  them  varies  from  1  to  8  grammes  (gr. 
15  to   3  ij-)  ill  twenty-four  hours. 

Tnternal  tise  of  alum. — Hitherto  we  have  studied  the  effect  of  alum 
upon  parts  with  which  it  was  in  direct  contact;  now  we  will  state  its  ac- 
tion on  the  internal  organs,  as  absorbed  by  the  priniiB  viae  and  brought 
indirectly  in  contact  with  the  various  tissues.  As  given  in  high  doses, 
internally,  it  is  most  used  for  htcmorrhages;  and  most  of  the  authors  cited 
in  this  article  report  many  instances  where  it  was  successful.  Hertz  ad- 
vised it  in  weakness  of  the  contractile  power  of  the  neck  of  the  bladder, 
and  the  resultant  incontinence;  Mead  and  Vogel  in  diabetes  (Mead: 
"Opera  omnia,"  lib.  II.,  p.  48;  Yogel:  "  De  cognoscendis  et  curandis 
morbis,"  p.  281);  Thompson,  in  obstinate  fluor  albus,  and  what  he  termed 
relaxation  of  the  seminal  vesicles  and  the  pollutions  and  spermatorrhoea 
which  he  considers  may  be  due  to  it.  Some  have  found  it  useful  in  ex- 
cessive debilitating  sweats. 

Some  practitioners,  misled  by  their  success  with  alum  injections  in 
the  treatment  of  certain  severe  leucorrhoeas  which  they  thought  symp- 
tomatic of  carcinoma  of  the  uterus,  have  claimed  alum  as  a  specific  in 
cancer,  and  have  freely  used  it  inwardly  and  outwardly,  with  various  suc- 
cess.    Recamier,  to  whom   science   owes   such  useful   studies  of  cancer, 


ASTRINGENTS.  99 

made  a  numerous  series  of  experiments  with  alum,  with  most  praise- 
worthy perseverance,  but  he  never  cured  a  cancer  which  was  diagnosti- 
cated by  the  speculum  and  the  touch. 

We  do  not  believe  in  the  febrifuge  virtues  of  alum,  in  spite  of  the  im- 
posing testimony  of  Boerhaave,  Lindt  and  Monro;  nor  do  we  believe, 
whatever  Milller  and  Fiirstenau  may  say  (Miiller:  "Diss,  de  Aluminis 
solutione  vitriolata;"  Fr.  Fiirstenau:  "  De  Alumine  dissertatio "),  that 
this  remedy  ought  to  be  ranked  with  cinchona  in  the  treatment  of  inter- 
mittents. 

Some  practitioners  claim  that  preparations  of  alum  cure  lead-colic  al- 
most as  surely  and  quickly  as  the  famous  Charite  treatment.  Grashius, 
the  author  of  this  method,  gave  from  |-  to  1  gramme  (gr.  7'5 — 15)  of  alum 
several  times  a  day.  ("  Diss,  de  Colica  pictorum,"  Amstelod.,  1752). 
Thomas  Percival,  ("Medical  and  Experimental  Essays,"  t.  IL,  p.  194), 
Quarin  ("  Animadversiones  practices  in  diversos  morbos),  gave  it  mixed 
in  sugar,  with  spermaceti,  or  gum  arable,  and  associated  it  with  opium. 
Kapeler,  a  physician  at  the  hopital  Saint-Antoine,  introduced  the  treat- 
ment here,  and  gives  for  six,  eight,  or  ten  days  in  succession  from  1  to  12 
grammes  of  alum  in  mucilaginous  julep  ("Arch.  gen.  de  med.,"  t.  XVIII., 
p.  370;  Memoire  de  M.  Mantanceix).  A  large  number  of  the  hospital 
physicians  of  Paris,  including  M.  Gendrin,  adopted  the  method  of  Grash- 
ius; but  the  latter,  thinking  that  the  action  of  alum  was  wholly  due  to  its 
excess  of  sulphuric  acid,  gave  for  several  days  from  4  to  8  grammes  (  3  i. — 
3  ii.)  of  acid  mixed  in  a  sufficient  quantity  of  ptisan  to  patients  suffering 
from  lead-colic.  He  has  probably  had  successes,  but  we  must  say  that 
our  experience  in  repeating  his  experiments  has  not  been  happy,  whereas 
the  alum  treatment  is  obviously  successful,  though  less  so  than  that  by 
purgatives  with  opiates. 

The  internal  dose  can  rarely  be  made  greater  than  8  grammes  at  a 
time  (  3  ii-)  without  causing  vomiting,  colic,  and  purging.  The  ordinary 
dose  is  30  or  40  centigrammes  (gr.  4j — 6)  several  times  a  day,  but  in  lead- 
colic  it  is  much  larger;  and  it  may  be  made  as  great  as  the  digestive  or- 
gans will  tolerate,  the  individual  susceptibility  being  our  only  guide. 


Bismuth. 

Internal  use. — Diseases  of  the  stomach. — It  is  certain  that  diseases  of 
the  stomach  are  beneficially  affected  by  subnitrate  of  bismuth;  but  the 
indications  given  by  Odier,  Carminati,  and  Bonnat,  are  too  vague  to  cor- 
respond with  the  present  state  of  science. 

The  subnitrate  is  suitable  for  persons  with  habitually  laborious  diges- 
tion and  a  tendency  to  diarrhoea. 

When  there  are  acid  eructations,  or  inodorous  flatus,  small  amounts 
of  carbonate  of  magnesia  or  bicarbonate  of  soda,  with  a  few  drops  of  laud- 
anum, should  be  added  to  the  bismuth. 


100  THER  APE  UTICS. 

When  there  are  fetid  eructations,  bismuth  almost  always  fails,  unless 
a  saline  purgative  has  been  previously  given.  It  is  therefore  particularly 
useful  in  subacute  and  chronic  gastritis,  and  in  gastralgia  complicated 
with  an  irritated  condition  of  the  gastric  mucous  membrane. 

But  when  gastralgia  is  accompanied  by  habitual  constipation,  when 
there  is  no  vomiting,  or  the  vomiting  is  purely  glairy,  insipid,  or  acid; 
when  it  complicates  chlorosis  and  alternates  (as  is  often  the  case)  with 
temporo-facial  neuralgia  or  rheumatism;  when  connected  with  hypochon- 
dria, leucorrhoca,  immoderate  discharge  from  piles,  or  any  flux  except 
diarrhoea,  subnitrate  of  bismuth  is  of  small  use. 

In  some  of  these  cases,  however,  it  may  prove  extremely  valuable,  if 
magnesia  be  added  to  it  for  the  purpose  of  neutralizing  the  acidity  of  the 
primae  viae  or  relieving  constipation.  The  American  powder,  or  Paterson's 
powder,  which  has  a  high  repute  in  the  United  States  and  England,  is 
nothing  but  bismuth  with  magnesia.  It  is  very  efficacious,  and  its  only 
inconvenience  consists  in  the  fixed  and  invariable  proportions  of  its  com- 
ponents. 

The  vomiting  of  children  during  dentition,  which  sometimes  precedes 
softening  of  the  mucous  membrane  of  the  stomach,  that  which  follows  the 
indigestions  caused  by  their  extreme  voracity,  and  that  whicli  accompa- 
nies thrush,  are  successfully  treated  by  subnitrate  of  bismuth. 

Diseases  of  the  intestine,  diarrhoea. — Of  the  diseases  of  the  intestine 
proper,  those  which  are  modified  by  bismuth  are  analogous  to  those  of  the 
stomach  which  are  cured  by  the  same  remedy. 

When  the  diarrhoea  succeeds  a  severe  dothinenteritis,  or  >vhen,  after 
the  fever  has  considerably  lessened,  the  evacuations  continue  excessive, 
bismuth  given  alone  in  the  dose  of  2-8  grammes  (  3  ss. — ii.)  per  diem  often 
does  much  good;  the  addition  of  a  little  aqua  calcis  (15  to  40  grammes — • 
3  iv. — x. — per  day)  is  often  very  useful.  Sometimes  it  fails  completely, 
if  each  dose  is  not  accompanied  bj'  a  very  minute  quantity  of  opium. 

In  the  diarrhoeas  which  seem  to  be  to  the  alimentary  canal  that  which 
pulmonary  catarrh  is  to  the  respiratory  organs,  and  which  may  properly 
be  called  intestinal  catarrh,  subnitrate  of  bismuth  is  decidedly  indicated 
after  the  first  febrile  heat  is  past.  It  may  be  taken  in  powder,  in  a  wafer, 
or  in  water  thickened  with  tragacanth:  in  the  evening  fasting,  and  in  the 
intervals  between  meals;  and,  to  children  who  dislike  this  way  of  taking- 
it,  it  may  be  given  at  the  moment  they  take  their  food. 

In  the  epidemics  of  cholera  which  desolated  France  in  1832,  1849,  and 
1854,  the  subnitrate  rendered  immense  service  in  the  premonitory  diar- 
rhoea. In  1832  but  few  physicians  chose  to  use  it;  in  1849  it  had  a  few 
more  supporters;  and  in  1854  its  use  was  so  general  that  the  druggists  dis- 
pensed enormous  quantities  every  day,  and  even  without  prescriptions, 
for  bismuth  is  one  of  the  very  few  remedies  which,  though  unquestionably 
efficacious,  are  nevertheless  perfectly  harmless. 

Opium  in  very  small  amounts  was  visually  associated  with  it.  This 
addition  is  really  useful  at  the  beginning  of  the  diarrhoea  and  when  it  is 


ASTRIKGENTS.  101 

active,  but  becomes  injurious  a  little  later;  and  a  strong  dose  of  bismuth 
night  and  morning,  with  a  little  Vichy  water  or  lime-water  at  meals, 
leaves  the  stomach  in  its  normal  tone,  while  it  acts  powerfully  against 
the  exaggerated  intestinal  secretions. 

The  subnitrate  is  especially  suitable  for  weakly  children,  who  have 
diarrhoea  on  the  slightest  occasion  and  especially  at  the  time  of  weaning, 
when  the  gastric  viscera  revolt  against  a  new  kind  of  food;  or  when  the 
diarrhoea  which  usually  accompanies  dentition  continues  after  the  erup- 
tion of  the  tooth. 

External  Use. 

Intestinal  hmmorrhage  during  typhoid  fever. — M.  Martineau  has- used 
high  doses  of  subnitrate  for  cases  of  intestinal  haemorrhage  supervening 
in  the  second  period  of  typhoid  fever.  He  has  given  it  in  the  dose  of  a 
gramme  (gr.  xv.)  every  hour  until  the  bloody  stools  wholly  cease.  The 
two  patients  recovered;  in  the  one,  there  was  no  more  internal  haemor- 
rhage after  the  30th  dose,  and  in  the  other,  after  the  40th. 

Ophthahnia. — M.  Bretonneau  is,  to  our  knowledge,  the  first  physician 
who  used  the  subnitrate  in  treating  external  maladies.  He  uses  it  chiefly 
in  catarrhal  ophthalmia  in  the  subacute  and  chronic  state.  He  blows  into 
the  eye  1  or  2  decigrammes  (gr.  \\ — 3)  once  or  twice  a  day,  or  he  re- 
verses the  patient's  head,  half  opens  the  eye,  and  places  in  it  a  pinch  of 
bismuth.  Sometimes  he  powders  in  the  same  way  sanious  or  sharply 
painful  ulcers.  In  cei'tain  dartres,  as  chronic  eczema  or  impetigo,  and  in 
ectropium,  he  quiets  the  itching  and  hastens  the  cure,  by  covering  the  skin 
with  a  paste  of  magistery  of  bismuth  and  water. 

Dysentery. — The  subnitrate  of  bismuth  is  wondei'fully  successful  in 
subacute  dysentery,  whether  rheumatismal,  paludal,  or  infectious,  or  even 
in  choleric  dysentery  after  the  bloody  discharge  is  over  and  the  secretion 
has  become  catarrhal  or  purulent. 

Our  friend.  Dr.  I^asegue,  by  a  happy  inference,  has  applied  in  acute 
and  chronic  colitis  the  topical  treatment  so  successfully  used  by  M.  Bre- 
tonneau. To  a  vehicle  composed  of  some  raw  eggs,  or  mucilage  of  gum 
tragacanth,  or  of  quince-pips,  he  adds  subnitrate  of  bismuth  in  the  dose 
of  2,  4,  and  up  to  10  grammes  (  3  ss. — iiss.),  injecting  the  mixture  into  the 
rectum,  after  fii'st  clearing  it  out  with  an  injection  of  water.  This  is  al- 
ways well  borne,  and  may  be  repeated  two  or  three  times  in  a  day — for 
several  weeks  if  necessary. 

Blennorrhatjia. — In  imitation  of  M.  Lasegue,  Dr.  Caby  introduces 
into  the  urethral  canal  and  the  vagina,  in  case  of  acute  or  chronic  blen- 
norrhagia,  a  thick  mixture  of  bismuth.  It  is  necessary,  in  the  case  of  a 
woman,  to  avoid  introducing  the  substance  into  the  bladder,  where,  if  it 
remained,  it  might  give  rise  to  a  calculus  {Bulletin  de  th'erapeutiquey 
1854  and  1858). 

It  is  our  custom,  after  modifying  the  acute  blennorrhagia  by  giving 


102  THERAPEUTICS. 

large  doses  of  extract  of  cubebs  from  the  outset,  to  order  the  following 
injection,  while  the  canal  is  still  painful: 

Neutral  glycerine 300  grammes. 

Subnitrate  of  bismuth 3         " 

This  mixture,  if  shaken  before  using,  that  the  j^owder  may  be  uni- 
formly suspended,  leaves  within  the  urethra  a  deposit  which  forms  a  dress- 
ing and  remains  till  the  next  urination. 

Two  military  surgeons,  MM.  Mourlon  and  Dauve,  have  shown  that,  in 
order  to  obtain  the  expected  results  from  subnitrate  of  bismuth,  it  must 
not  have  an  acid  reaction;  if  it  should  have,  it  must  be  washed  with  water 
or  nitrate  of  ammonia  {Bulletin  de  th'erapeutique,  1860). 

Affections  of  the  skin. — Bismuth  forms  an  ingredient  in  absorbent 
powders.  In  children,  moisture  of  the  skin  is  relieved  by  powder  of 
starch,  of  rice,  or  better,  lycopodium.  The  powder  of  Ij'copodium  being 
yellow,  ladies  Avill  not  use  it  on  the  neck  and  face,  and  prefer  the  white 
powders;  that  of  rice  is  almost  exclusively  used,  and  sometimes  very  fine 
starch,  to  each  of  which  subnitrate  of  bismuth  is  often  added.  The  fol- 
lowing are  the  most  frequently  used: 

Poiidre  d  la  Violette. 

Wheat  starch 6  kilogr.  =  3  192 

Powdered  orris  root 1       "       =  3  32 

Powdered  acacia 100  gram.   =  3  25 

Powdered  cloves 10     "        =  3  2^ 

Poudre  d  la  Pistache. 

Pistachio  starch 3,500  parts. 

Brianyon  chalk,  powdered 3,500 

Essence  of  rose 2 

Essence  of  lavender 1      " 

Powder  for  the  Face. 

Starch 500  parts. 

Subnitrate  of  bismuth 113      " 

A  White  Wash  for  the  Face. 

Rose-water,  or  orange-flower  water  .' b&  centilitres. 

Oxide  of  bismuth 113  grammes. 

French  white  is  composed  of  talc  powdered  and  passed  through  a 
silk  sieve  (Piesse:  Des  odeurs,  des parfums  et  des  cosn^etiques). 

M.  Las^gue  spreads  a  pulp  of  bismuth  and  water  over  the  surface  of 
moist  dartres,  and  over  that  puts  a  starch  poultice,  to  which  a  little  gly- 
cerine has  been  added  to  prevent  drying. 


I 


ASTRINGENTS.  103 

Chronic  coryza. —  Ozaena. — Monneret  has  used,  in  ozsena,  powdered 
subnitrate  of  bismuth  sprinkled  with  flour  of  melilot.  M.  H.  Gintrac  as- 
sociates with  it  starch  or  rice  fecula;  often  a  little  muriate  of  morphia. 

tiiniif for  Coryza. 

Hydrate  of  oxide  of  bismuth 2  grammes  =  3  ss. 

Powdered  benzoin 1  "        =gr.  15 

Muriate  of  morphia 0.02    "        =gr.  0*3 

Two  to  six  pinches  daily  (Van  den  Corput). 


Tonic  Asteixgext  Treatment. 

It  may  seem  singular  that  the  substances  which  compose  this  cate- 
gory are  ranked  among  tonics,  since,  when  locally  applied,  they  seem  to 
diminish  the  vital  properties  of  tissues.  These,  however,  in  opposition 
to  the  other  tonics,  produce  their  therapeutic  action  through  the  inter- 
vention of  very  perceptible  physiological  phenomena;  the  sedative  action 
is  only  transient,  and  soon  gives  place  to  the  local  tonic  effects  which 
form  their  proper  therapeutic  action. 

This  class  of  tonics  always  acts  by  the  presence  of  an  acid,  a  salt  with 
excess  of  acid,  or  tannin,  which  is  itself  an  acid,  gallic  acid  combined 
with  coloring  matter  and  various  other  substances.  The  most  important 
of  these  remedies  in  the  mineral  kingdom  are  diluted  sulphuric  acid  and 
its  compounds,  as  eau  de  Rabel  (alcoholized  sulphuric  acid),  alum,  the 
sulphates  of  iron  and  zinc,  the  salts  of  lead;  in  the  vegetable  kingdom, 
tannin,  gallic  acid,  nut-gall,  rhatany,  pomegranate,  catechu,  kino,  the 
wild  quince,  bistort,  tormeutilla,  I'ed  or  Provence  roses,  etc. ;  and  finally, 
cold. 

Laid  directly  on  the  skin,  a  mucous  membrane,  or  a  sore,  whether  re- 
cent or  old,  these  substances  manifest  true  tonic  effects,  in  the  rigorous 
and  etymological  sense;  that  is,  they  produce  a  fibrillary  constriction,  a 
tonicity  which  effaces  the  organic  interstices  and  the  cavities  of  capilla- 
ries, expelling  the  liquids,  suspending  exhalation,  producing  cold,  pallor 
and  a  well-known  sensation  of  wrinkling  and  condensation. 

If  the  application  is  not  continuous,  and  a  reaction  is  allowed  to  fol- 
low this  primary  anti-vital  impression,  contrary  phenomena  will  soon 
appear.  The  tissue  will  become  redder,  warmer,  more  sensitive,  thicker 
and  firmer  than  before  the  tonic  action;  that  is,  through  that  instinct  of 
vital  reaction  which,  properly  measured,  constitutes  the  vis  medicatrix, 
an  excess  of  vascularity  and  of  all  the  associated  acts  will  soon  replace 
that  tonic  spasm  which  had  effaced  the  vascularity  of  the  part  and  weak- 
ened all  the  organic  acts  which  depend  on  it. 

But  if  the  contact  with  the  astringent  substance  is  continuous,  or 
promptly  renewed  before  the  return  of  vascularity  takes  place,  the  living 


104  THERAPEUTICS. 

tissues  remain  in  that  state  of  condensation,  numbness,  rigidity  and 
pallor.  They  are  cold,  insensible,  stiff,  mortified  without  yielding  to  de- 
composition or  gangrene;  they  are  tanned  like  dead  hides;  and  thi^ 
avoidance  of  sphacelus,  which  may  be  compatible  with  so  diminished 
vitality,  is  no  doubt  due  to  the  fact  that  the  liquids,  the  parts  most  liable 
to  decomposition,  have  deserted  the  solids  which  are  the  less  putrescible  in 
proportion  as  they  are  more  dense.  It  is  probable  that  the  combination 
of  the  tanning  principles  with  the  molecules  of  the  tissues  renders  them 
less  susceptible  to  the  septic  fermentation. 

This  is  what  happens  when  a  long  and  unbroken  course  of  topical 
astringents  is  kept  up.  But  in  the  most  common  cases,  astringents  are 
applied  only  in  order  to  give  atonic  and  relaxed  tissues  adequate  tonicity, 
and  then  no  such  extreme  effects  are  sought  after. — Before  leaving  the 
physiological  action  of  astringent  tonics,  we  should  say  that  this  action 
is  energetic,  and  really  tonic  and  durable,  in  proportion  as  it  is  effected 
by  vegetable  astringents,  which  contain  the  largest  proportion  of  tannin 
and  gallic  acid;  and  that,  when  produced  by  the  mineral  acids  or  salts, 
it  is  less  enduring  and  strengthening,  though  at  first  as  vigorous  and  per- 
ceptible. 

The  general  physiological  action  of  the  astringent  tonics  will  appear 
less  satisfactory  and  constant,  and  much  less  related  to  their  therapeutic 
effects.  In  this  respect  they  seem  absolutely  opposed  to  the  end  of  tonic 
treatment. 

In  small  doses,  they  produce  in  the  mouth,  and  soon  in  the  gullet  and 
stomach,  a  sensation  of  contraction  which  is  really  curious,  and  which  in 
the  case  of  tannin  gives  for  an  instant  the  impression  that  the  cavity  of 
the  mouth  is  almost  obliterated.  An  extraordinary  appetite  usually  suc- 
ceeds this  first  impression.  They  constipate  and  suppress  perspiration, 
which  is  probably  the  cause  of  the  diuresis  which  often  follows  their  use. 
In  larger  doses,  the  sensation  of  constriction  of  the  gastric  cavity  changes 
to  cardialgia,  nausea,  vomiting,  and  those  pains  of  the  stomach  vulgarly 
known  As  cramps,  which  in  a  few  moments  extend  to  the  intestines. 

It  is  obvious  that  these  substances,  by  producing  this  contraction  and 
fibrillary  spasm  of  the  mucous  surfaces,  must  singularly  interfere  with 
absorption  by  these  surfaces,  and  must  therefore  be  very  slowly  absorbed. 
Nevertheless,  they  are  absorbed,  and  tannin  is  found  in  the  urine  as 
gallic  or  pyrogallic  acid  (Frazer).  The  astringent  tonics,  by  the  aid  of 
the  greater  circulation,  apply  their  action  to  all  the  tissues,  to  all  the 
exhaling  surfaces,  the  action  of  which  they  impair  in  the  same  way  as  when 
they  act  topically,  though  in  a  much  smaller  degree.  This  granted, 
we  shall  not  be  surprised  to  learn  that  dyspepsia,  suspension  of  secretions, 
reduction  and  feebleness  of  the  heart's  action,  emaciation  and  atrophy, 
are  among  the  general  effects  of  these  medicines  when  given  largely. 
From  all  these  local  and  general  physiological  effects,  however,  many  of 
which  are  dangerous  and  injurious,  very  valuable  therapeutic  results 
ensue,  at  which  we  will  now  cast  a  rapid  glance. 


ASTKINGENTS.  105 

Of  these  physiological  effects,  some  may  find  their  topical  value  in 
exciting  vital  reaction  in  parts  which  need  it.  Such  are  those  which  im- 
mediately produce  or  develop  vascularity  and  all  the  consequences  thereof, 
as  a  result  of  the  immediate  movement  of  concentration  and  sedation 
which  follows  tlie  application  of  the  astringent.  But  we  need  not  speak 
of  this  therapeutic  action  in  this  place.  The  remedies  we  are  now  con- 
sidering are  never  used  for  this  purpose,  for  several  reasons:  first,  be- 
cause there  are  more  certain  means  of  reaching  the  object,  direct  and 
infallible  means  of  developing  a  local  reaction,  which  will  be  studied 
under  the  head  of  epispastics,  irritants  and  rubefacients;  and  second, 
because  when  a  vascular  reaction  is  to  be  produced  in  a  tissue  by  means 
of  previous  sedation,  cold  is  commonly  used.  Cold  is  therefore  an  indi- 
rect topic;  and  if  we  do  not  speak  of  it  here,  it  is  because  it  is  more 
specially  applicable  to  other  affections,  and  particularly  when  an  absolute 
and  very  powerful  sedative  is  wanted. 

The  immediate  effects  of  continued  or  repeated  topical  applications  of 
astringent  tonics,  consist  in  enfeeblement  of  the  vascularity  and  the 
vital  properties  of  the  tissues,  and  especially  in  the  persistence  of  a  con- 
tracted and  toned  condition  ;  these  effects  are  often  put  to  good  use. 

At  the  beginning  of  congestions,  fluxions  and  phlegmasite,  a  great  and 
rapid  local  development  of  the  capillaries  occurs.  The  blood  enters  the 
vessels  more  freely  and  rapidly,  increasing  their  calibre,  and  penetrating 
many  which  did  not  previously  admit  it.  A  new  and  richer  circulation 
seems  to  be  created.  It  is  natural  to  seek  to  counterbalance  this  expan- 
sive force  by  reducing  the  dilated  vessels  to  their  normal  volume,  by 
forcing  those  which  were  not  intended  to  receive  blood  to  return  to  their 
normal  sensibility  and  calibre;  in  a  word,  by  opposing  the  impending 
excess  of  vascularity,  the  prolonged  residence  of  the  blood  in  the  parts, 
the  unwonted  stimulation  which  it  maintains,  and  the  lesions  and  dis- 
organizations which  result.  This  object  may  perhaps  be  successfully 
fulfilled  by  the  application  of  astringent  tonics  which,  restoring  to  the 
vessels  their  tone  and  expelling  the  excess  of  liquids,  are  capable  of  pro- 
ducing a  favorable  modification,  and  preventing  inflammation  and  its  con- 
sequences by  dissipating  the  process  in  its  first  stage. 

But  important  conditions  must  be  fulfilled,  in  order  that  this  abortive 
treatment  may  succeed  without  doing  harm. 

First,  we  must  be  on  hand,  so  to  speak,  at  the  beginning  of  the 
phlogosis,  before  the  alterant  forces  of  the  part  (to  use  Grimaud's  expres- 
sion) are  modified.  Nothing  must  have  taken  place  beyond  the  afflux  of 
blood  and  the  lesion  of  organic  sensibility  which  so  rapidly  drew  it  into 
the  region.  The  application  of  astringent  tonics  may  then  have  the 
double  object  of  restoring  this  sensibility  to  its  normal  type,  through  their 
direct  sedative  power,  and  of  expelling  the  liquids  attracted  by  this  meta- 
phorical thorn.  It  was  long  ago  said,  "  ubi  stimulus,  ibi  fluxus."  Such  is 
usually  the  order  of  the  phenomena;  but  the  effect  soon  becomes  the 
cause  in  turn.     The  astringent  tonics  weaken  the  stimulus,  and  conse« 


106  THERAPEUTICS. 

quently  the  fluxus,  which,  disappearing,  will  cease  to  occasion  the  con- 
tinuance and  the  return  of  the  stimulus. 

Nevertheless,  in  the  most  important  cases  this  sharp  abortive  treat- 
ment is  formally  contra-indicated.  We  can  see  that,  when  the  cause  of 
the  fluxion  and  phlegmasia  has  been  momentary  and  transient,  and  has 
withdrawn  after  acting  without  having  any  besides  ephemeral  results, 
that  the  use  of  astringent  tonics  is  followed  by  a  final  and  harmless  de- 
parture of  the  fluxion.  But  these  cases  are  almost  limited  to  the  effects 
of  external  physical  or  chemical  action,  the  fluxions  and  congestions 
termed  traumatic.  A  part,  however,  of  those  which  originate  in  internal 
pathology  may  be  assimilated  to  these.  When  the  physician  is  called  at 
the  very  beginning  of  the  phlegmasia,  and  judges  that  the  intensity  and 
duration  of  tlie  cause  are  not  such  as  to  inevitably  involve  a  regular  and 
complete  inflammation,  he  should  promptly  and  methodically  use  the 
astringent  tonics.  They  should  be  used  methodically  and  continuously, 
because,  if  used  for  a  short  time  only,  and  not  until  the  fluxion  is  proba- 
bly dispersed,  there  would  be  a  risk  of  acting  contrary  to  the  intention, 
and  adding  force  to  the  evil  we  desire  to  expel. 

This  success  must  not  be  expected  when  the  fluxion  or  phlegmasia  is 
the  product  of  a  general  internal  cause  which  is  not  eliminated  from  the 
system  by  the  local  inflammatory  action  which  it  causes.  Even  when 
this  general  internal  cause  does  not  survive  the  disappearance  of  the 
j^hlegmasia  or  fluxion,  which  is  its  anatomical  expression,  and  when  the 
disappearance  forms  a  definitive  crisis,  or  judgment,  to  use  the  Hippo- 
cratic  expression,  the  astringent  tonics  are  still  full  of  danger,  since  they 
cannot  succeed  until  the  close  of  the  phlegmasia,  which,  in  the  case  sup- 
posed, must  follow  its  course  to  the  very  end.  They  will  therefore  be 
excluded  in  all  inflammatory  affections  produced  or  maintained  by  inward 
causes,  Avhether  critical  and  decisive  of  the  disease,  as  are  the  febrile  ex- 
anthemata, or  whether  they  are  caused  by  a  principle  which  is  not  ex- 
hausted and  may  be  reproduced  indefinitely  under  the  same  or  different 
forms,  as  in  the  spontaneous  erysipelatous  eruptions,  dartres,  syphilis, 
etc. 

Independently  of  the  preceding  cases,  there  are  others,  not  closely 
analogous,  but  which  contradict  the  use  of  astringent  tonics  as  means  to 
produce  the  disappearance  of  commencing  inflammatory  acts.  These  are 
cases  where  the  explosion  of  the  fluxion  or  phlogosis  depends  on  a  ple- 
thora as  regards  the  quantity  or  the  quality  of  the  blood;  in  scholastic 
terms,  "  plethora  quoad  molem,  plethora  quoad  crasim."  The  first  resource 
is  then  the  temperant  or  evacuant  antiphlogistic  treatment,  and  it  would 
involve  great  risk  if  we  attended  solely  to  the  indications  presented  by 
the  local  affection,  disregarding  the  general  condition,  which  may  repro- 
duce the  affection  in  a  graver  form  elsewhere. 

The  fluxions  and  phlegmasia  amenable  to  the  abortive  treatment  by 
astringent  tonics  are  those  seated  externally  in  the  cutaneous  envelope 
or  the  parts  of  the  mucous  membrane  which  are  accessible.     The  secunda? 


ASTKINGENTS.  107 

vise  are  never  to  be  used  for  introducing  these  substances  into  the  general 
system  in  the  abortive  treatment  of  local  inflammation. 

Mineral  acids,  however,  are  sometimes  used  with  success  in  chronic  in- 
flammations of  the  skin  and  the  uterus,  as  sulphuric  acid  lemonade  in  ob- 
stinate dartres,  alum  and  tannin  in  chronic  metritis,  etc. 

Some  have  attempted  to  act  by  tonic  astringents  upon  the  entire  cir- 
culatory system,  in  the  same  way  as  upon  portions.  To  suppress  obsti- 
nate fevers,  chiefly  remittent  and  intermittent  nervous  fevers,  they  have 
plunged  the  whole  body  into  cold  baths  containing  in  solution  tannin, 
alum,  acetate  of  lead,  etc.  This  bold  practice  is  entirely  exceptional  and 
very  rare.  When  it  is  thought  proper  to  resort  to  it,  the  principles  hold 
good  which  we  established  in  regard  to  commencing  phlegmasite  and 
fluxions. 

In  chronic  phlegmasige,  the  indications  do  not  exactly  change.  The 
remedy  acts  in  essentially  the  same  way  physiologically,  but,  the  affected 
parts  being  in  a  different  condition  and  the  object  of  acting  being  dif- 
ferent, different  therapeutic  effects  are  obtained. 

The  habit  of  inflammatory  hyj^erjemia,  the  changes  produced  in  a  tis- 
sue long  subjected  to  phlegmasia?,  have  remarkably  weakened  the  capil- 
laries. They  no  longer  have  the  "  sufiiciens  robur  "  of  Stahl,  to  react  and 
establish  a  normal  circulation  and  nutrition.  They  are  stricken  with 
atony.  We  assume  that  the  local  or  general  cause  of  the  phlegmasia  is  re- 
moved, and  that  nothing  remains  but  the  alteration  of  the  tissue,  whose  or- 
ganic sensibility  and  latent  contractility  are  weak,  act  "  segniter  et  otiose," 
as  Stahl  says;  often  the  only  conditions  which  maintain  the  chronic  in- 
flammations. During  an  acute  phlegmasia  there  comes  a  moment  when 
the  capillaries  of  the  part  are  distended  beyond  measure,  as  it  were,  by 
a  weight  of  blood  against  which  they  cannot  react  to  expel  and  distribute 
it.  If  resolution  is  prevented  by  the  persistence  of  the  cause,  the  debility 
of  the  entire  system,  or  only  that  of  the  affected  tissue,  the  passive  re- 
laxation and  distention  of  the  vessels  persists,  and  becomes  a  habit;  the 
local  reaction  is  languid,  but  it  retains  the  organic  condition,  and  often 
the  excess  of  secretion,  which  belong  to  inflamed  parts.  These  atonic 
conditions  belong  chiefly  to  the  mucous  membranes.  An  agent  which 
strengthens  these  relaxed  tissues,  and  re-establishes  the  tonicity  which 
was  destroyed  by  the  repeated  extra-physiological  molimen  sanguineum, 
will  effect  a  cure.  But  what  sagacity  and  practical  talent  is  required  to 
distinguish  these  cases  from  those  in  which  the  task  is  not  that  of  tanning 
or  condensing  a  living  tissue  in  order  to  restore  it  to  physiological  condi- 
tions !  The  same  difficulties  are  here  repeated  which  we  noted  above,  in 
connection  with  the  abortive  treatment  of  acute  commencing  phlegmasiie. 
There  is  another  point,  also,  which  needs  to  be  carefully  considered. 

Supposing,  as  we  have  just  done,  that  the  entire  trouble  consists  in 
simple  atony  of  tissue,  and  that  the  inflammation  consists  almost  wholly 
of  certain  anatomico-pathological  phenomena  and  an  increased  flux,  as  is 
seen  in  all  the  chronic  catarrhs  (leucorrhoea,  bronchorrhoea,  gonorrhoea, 


108  THERAPEUTICS. 

etc);  supposing,  also,  the  absence  of  any  principle  capable  of  reprodu- 
cing the  affection,  its  rapid  cure  by  astringent  tonic  applications,  without 
precautions,  would  often  be  followed  by  bad  consequences,  as  every  day's 
experience  attests.  The  membrane  affected  with  the  chronic  catarrh  has 
become  an  accidental  emunctory,  which  by  habit  is  grown  to  be  so  neces- 
sary that  the  suppression  of  its  discharge  must  be  undertaken  with  cir- 
cumspection. It  must  be  temporarily  replaced  by  supplementary  evacu- 
ations, by  a  prophylactic  treatment  with  exutories,  purgatives,  vegetable 
depuratives,  sulphurous  waters,  gymnastics,  etc. 

The  same  precautions  are  not  necessary  when  the  astringent  tonics  are 
used  as  resolvents,  repercussives,  upon  infiltrated  parts,  engorgements, 
tumors  generally  of  external  causation,  as  strains,  effusions,  ecchymoses, 
oedemas,  burns,  where  the  object  is  to  assist  the  absorption  of  the  effused 
liquids  and  lessen  the  sensibility  and  pain,  as  is  done  by  compression. 
They  are  indicated  whenever  we  wish  to  cause  the  atrophy  of  a  tissue; 
and  then  they  should  be  used  vigorously  and  continuously,  as  in  the  case 
of  aneurism,  etc.  Baths  with  the  decoction  or  solution  of  astringent 
tonics  may  be  of  use  in  those  cases  of  scorbutic  ecchymoses  and  hemor- 
rhagic purpura,  when  atony  of  the  integument  seems  to  be  the  chief  fea- 
ture of  the  malady.  It  is  unnecessary  to  urge  the  cicatrizing  properties 
of  these  remedies.  They  exist  only  in  the  case  of  ulcers  and  wounds, 
where  cicatrization  is  retarded  by  atony  of  ulcerated  parts,  fungous  gran- 
ulation, and  the  pale  color  of  the  tissues.  These  applications  then  act 
like  compression,  which  is  so  powerful  in  curing  fungous,  varicose  and 
atonic  ulcers. 

The  local  use  of  these  remedies  is  never  so  promptly  and  manifestly 
of  use  as  in  haemorrhage  from  wounds  or  by  exhalation,  whenever  the 
remedy  can  be  applied  directly  to  the  part  whence  the  blood  issues.  The 
remedy  here  fulfils  a  therapeutic  end  by  means  of  a  double  physiological 
action;  to  wit,  the  strictum,  or  contraction  of  the  extremities  of  the  cap- 
illaries, whether  cut,  or  allowing  the  blood  to  transpire  by  their  exha- 
lant  orifices;  and  coagulation  of  fibrine,  which,  becoming  instantly  plastic 
under  the  action  of  astringents,  adheres  in  such  a  way  as  to  obliterate  the 
bleeding  orifices. 

Capillary  traumatic  haemorrhage  yields  to  this  treatment.  Sponta- 
neous haemorrhage,  though  capillary,  3aelds  less  surely,  since  a  cause,  a 
molimen,  maintains  and  renews  it,  which  is  not  reached  by  the  remedy; 
while  in  the  former  there  is  nothing  but  a  physical  lesion  of  the  small 
vessels,  which,  when  once  contracted  and  plugged,  are  exposed  to  no 
further  cause  of  haemorrhage. 

There  are  yet  other  indications  which  call  for  other  modes  of  the  local 
action  of  astringent  tonics.  The  combination  of  these  substances  with 
albumin,  fibrin  and  gelatin,  as  we  have  said,  doubtless  produces  an  anti- 
septic action,  which  preserves  them  from  putrefying,  as  we  see  in  dead 
skin  when  tanned.  This  observation  is  often  made  of  use  in  dressing 
sores  which  tend  to  mortify  or  which  discharge  septic  and  decomposing 


ASTlilNGENTS.  10t> 

matter.  The  barks  which  are  rich  in  tannin  are  usefully  applied  in  pow- 
der to  foul  gangrenous  ulcers,  to  wounds  complicated  with  hospital  gan- 
grene— in  fact,  to  all  tissues  threatened  with  decomposition  and  sphacelus. 
We  then  use  the  tonic  property  of  these  substances,  which,  relieving  the 
tissues  of  excessive  moisture,  and  checking  exuberant  granulation,  sup- 
press the  chief  elements  of  putrid  fermentation;  and  by  their  conserva- 
tive, and  as  it  were  mummifying  action  on  animal  tissues,  the  deleterious 
influence  of  portions  where  putrefaction  has  commenced  is  neutralized. 

If  we  now  pass  to  the  indications  for  internal  use,  we  shall  again  find 
the  three  classes  of  physiological  effects  which,  as  we  saw,  form  the  basis 
of  the  immediate  tonic  action  of  these  remedies.  They  act,  therefore: 
1,  by  their  tonic  and  astringent  effect  upon  the  fibre;  2,  by  their  coagu- 
lant properties;  and  3,  by  their  antiputrescent  virtue. 

In  treatment,  we  use  the  former  of  these  actions  in  diseases  totius 
substantive,  marked  by  those  changes  in  the  solids,  for  which  we  lately 
directed  topical  treatment,  the  atony  being  partial  and  accessible  to 
direct  applications. 

Scorbictus,  purpura,  'Werlhofs  disease. — These  changes  are  general, 
intimate,  deep,  and  require  modifiers  which  have  the  same  characters; 
which  can  only  reach  them  through  the  secundae  viae,  mixed  with  the 
fluid  which  penetrates  and  recomposes  all  the  organic  molecules.  This 
action  is  much  less  certain  and  manifest  than  that  which  takes  place  dur- 
ing the  direct  contract  between  the  remedy  and  the  relaxed  fibre;  the 
reason  for  which  is  obvious. 

Yet  we  cannot  deny  the  existence  of  this  action,  which  is  of  most 
notable  benefit  in  scorbutus.  We  will  not  here  discuss  the  question 
whether  it  is  the  solids  or  the  liquids,  the  blood,  which  are  primarily  af- 
fected in  this  severe  disease;  the  importance  of  the  question  disappears 
when  we  consider  it  simply  from  the  point  of  view  of  the  therapeutic  ac- 
tion of  astringent  tonics.  In  the  admirable  pages  of  Broussais  the  sub- 
ject is  treated  with  the  force,  abundance  and  fulness  of  proof  which  dis- 
tinguish this  writer  when  he  is  on  the  right  side;  as  regards  clinical 
points,  there  is  no  better  work  to  consult  than  that  of  Lind. 

At  all  events,  the  crasis  of  the  blood  is  attenuated  in  well-marked  scor- 
butus; it  loses  its  coagulability,  its  solid  or  organizable  parts  are  as  if 
dissolved  in  their  fluid  vehicle.  The  solids  share  in  this  tendency  to  a 
great  degree;  they  are  atonic,  permeable,  friable,  can  be  penetrated  and 
traversed  by  the  blood  at  all  points  where  its  passage  ought  to  be  resist- 
ed. The  astringent  tonics  combat  this  double  alteration,  both  by  their 
power  of  coagulating  the  blood  and  by  their  tonic  effect  upon  the  fibril- 
lary contraction. 

We  need  not  state  that  these  remedies,  employed  successively,  have 
but  a  temporary  and  palliative  effect  upon  the  scorbutic  constitution,  nor 
that  this  effect  must  be  maintained — and,  as  it  were,  fed — by  agents 
which  essentially  change  the  character  of  the  nutrition;  to  which  end 
better  material  for  assimilation  is  needed.     The  astringent  tonics  satisfy 


110  THE  R  APEUTICS. 

dominant  and  urgent  indications,  while  waiting  for  more  real  and  radi- 
cal aid,  which  must  come  slowly,  and  sometimes  cannot  be  rendered  at 
all. 

These  urgent  indications  chiefly  rest  upon  the  existence  of  haemor- 
rhage, which  threatens  life  directly;  and  also  from  the  softening  and  fria- 
bility of  the  solids,  which  may  reach  such  a  point  that  the  chief  organs,  as 
the  heart  and  brain,  fall  into  a  state  of  flaccidity  and  deliquium  which  ren- 
ders their  continued  functions,  and  even  their  existence,  impossible.  In  or- 
der that  such  organs,  including  the  stomach,  with  its  mucous  and  muscular 
coats  so  softened  and  weak,  may  become  capable  of  reacting  upon  the 
aliments  and  the  analeptic  tonics  presented  to  them,  which  are  the  only 
curative  remedies  in  these  cases,  it  is  necessary  in  these  cases  to  bring 
these  organs  previously  into  a  condition  to  bear  and  digest  such  sub- 
stances. This  preparatory  treatment  has  the  astringent  tonics  for  its 
agents;  these,  giving  an  instant  impression,  conveying  to  the  solids  a 
momentary  "  sufficiens  robur  "  and  tonicity,  place  them  in  relation  with  the 
analeptic  tonics,  which,  once  tolerated  and  assimilated,  fundamentally 
renew  the  blood  and  the  solids  by  good  nutrition. 

The  flrst  principles  of  treatment  in  scorbutus  inform  us  that  the  ana- 
leptic tonics,  which  undertake  the  reformation  of  impaired  nutrition,  are 
rarely  taken  from  the  class  of  drugs  and  foods  whose  general  indications 
we  are  about  to  study,  but  from  fresh  vegetable  foods,  fresh  young  meat, 
certain  stimulant  members  of  the  crucifera?,  and  certain  temperant  vege- 
table acids,  for  the  deprivation  of  these  foods  is  often  one  of  the  chief 
causes  of  scurvy. 

All  excessive  fluxes,  all,  even  of  the  active  ha?morrhages,  may  be  bene- 
ficially combated  with  astringent  tonics  taken  internally  for  the  purpose 
of  producing  mediately  in  the  fibre  a  contraction  which  will  stiffen  the 
tissues  and  render  them  less  permeable  to  the  liquids  which  flow  thither, 
and  by  escaping  produce  the  flux.  It  is  also  observed  that  astringent 
tonics,  suitably  diluted  in  water  and  taken  internally,  exercise  a  sedative 
influence  upon  the  greater  circulation,  lessen  the  force  and  frequency  of 
the  heart's  beats,  moderate  the  heat,  and  to  their  depressing  action  upon 
the  vascularity  of  the  tissues  add  a  moderating  effect  upon  the  energy  of 
the  circulation,  and,  indirectly,  a  check  upon  the  vitality  and  the  turges- 
cence  of  the  parts  through  which  the  flow  or  the  bleeding  takes  place. 

Asiatic  cholera,  among  the  leading  symptoms  of  which  is  an  excessive 
secretion  from  the  gastro-intestinal  mucous  membrane  of  most  fatal  im- 
port, has  been  treated  by  astringent  tonics  for  the  purpose  of  suppressing 
this  irrepressible  discharge.  This  indication  seemed  the  most  pressing, 
natural,  and  radical,  since  the  majority  of  practitioners  regard  the  cool- 
ness, the  gradual  extinction  of  circulation  and  breathing,  as  the  necessary 
result  of  the  excessive  flux.  The  source  of  the  danger  is  thus  supposed 
to  be  reached  and  destroyed,  and  all  the  danger  conjured.  But  while  we 
often  succeed  in  arresting  the  alvine  discharges,  the  progress  of  the  fatal 
symptoms  is  little  checked,  or  not  at  all.     The  cold  stage,  asphyxia,  lead 


ASTRINGENTS.  Ill 

the  way  to  the  tomb,  and  a  wretched  symptomatic  treatment  is  all  we  have 
accomplished. 

A  very  simple  observation,  1  think,  ought  to  limit  confidence  in  such 
means  ;  in  cholera,  the  gravity  of  the  symptoms  and  the  rapidity  of  death 
are  not  in  direct  ratio  to  the  abundance  or  frequency  of  the  gastro-intes- 
tinal  discharges;  every  one  has  seen  dry  choleras,  that  is,  an  algid  stage, 
asphyxia,  etc.,  with  a  complete  suppression  of  all  secretion  and  exhala- 
tion from  the  intestines  or  otherwise.  The  agony  is  the  first  symptom, 
and  the  patient  dies  without  having  one  stool,  or  only  a  tenth  part  of 
what  is  to  be  seen  in  many  other  cases  which  do  not  at  all  resemble 
cholera. 

Is  there  in  algid  pernicious  fevers,  in  the  mortal  chill  of  some  intermit- 
tents,  in  the  lightning-stroke  of  emotion  which  kills  at  once,  in  the  incura- 
ble chill  caused  by  the  introduction  of  certain  poisons,  any  evacuation 
which  explains  such  effects  ? 

It  is  just  to  add  that  we  do  not  regard  the  astringent  tonics  as  contra- 
indicated  for  the  purpose  of  limiting  the  excessive  discharge  of  Asiatic 
cholera,  when  the  symptom  is  proniinent,  may  increase  the  general  col- 
lapse, hasten  the  extinction  of  the  strength,  and  during  the  period  of  re- 
action may  aggravate  those  affections  of  the  digestive  organs  and  those 
endless  inflammations  which  make  convalescence  so  difficult  and  danger- 
ous. But  these  remedies,  in  our  view,  have  but  a  secondary  place,  and 
must  not  release  us  from  the  duty  of  obeying  the  more  capital  indications, 
which  we  are  not  now  studying. 

Taken  internally,  astringent  tonics  resist  hamiorrhage,  as  much  and 
perhaps  more  by  aiding  coagulation  as  by  producing  fibrillary  contraction 
in  the  tissues.  The  more  blood  has  been  lost  in  a  luemorrhage,  the  more 
one  must  lose,  because  this  fluid  is  gradually  impoverished,  and  the  sys- 
tem loses  that  power  of  a  spontaneous  arrest  of  haemorrhage  which  is  due 
to  the  plasticity  and  the  coagulation  of  the  blood,  which,  however,  the 
nisus  hfemorrhagicus  may  continue,  solidly  obliterates  all  the  channels  of 
exit.  In  these  cases  the  remedy  effects  a  great  benefit;  it  mingles  with 
the  blood,  increases  its  coagulability,  makes  its  passage  through  the  small 
vessels  of  Boerhaave  slower  and  more  difficult,  and  thus  checks  its  dis- 
charge. 

We  have  seen  how  the  astringent  tonics,  applied  to  parts  threatened 
with  putrescence,  improve  the  quality  of  suppuration  and  arrest  gan- 
grene. In  such  general  diseases  as  are  marked  by  a  strong  tendency  of 
the  fluids  and  solids  to  yield  to  the  laws  of  brute  chemistry,  in  the  typhoid 
affections,  those  pestilential  putrid  fevers,  whatever  their  place  in  nosol- 
ogy, but  more  particularly  the  entero-mesenteric  in  a  putrid  form,  and  in 
all  morbid  states  bearing  the  stamp  of  putridity,  the  internal  use  of  as- 
tringent tonics  has  always  been  of  acknowledged  value  as  opposed  to 
septicism,  and  the  general  dissolution  of  the  blood  and  the  solids.  Sul- 
phuric acid  lemonade  and  slightly  aluminous  drinks  have  been  principally 
used  for  this  purpose.     The  last  period  of  typhoid  diseases    (using  the 


112  THEE  APE  UTICS. 

term  in  its  widest  and  most  correct  sense)  is  the  chief  time  for  these  reme- 
dies; at  this  time  it  is  also  desirable  to  raise  the  tone  of  the  stomach,  re- 
animate the  digestive  functions,  moderate  diarrhoea  and  the  tendency  to 
intestinal  hsemorrhage,  which  is  then  too  frequent.  They  also  restrain 
fever;  and  these  effects  have  more,  perhaps,  to  do  with  recovery  than  the 
directly  antisejDtic  action. 

In  speaking  of  the  physiological  action  of  astringent  tonics  used  in- 
ternally, we  mentioned  the  injury  to  the  digestive  power,  arrested  nutri- 
tion, suspension  of  secretion,  emaciation,  and  general  atrophy  which 
might  result  from  an  imj^rudent  and  protracted  use  of  them.  These  ob- 
servations furnish  the  ground  of  some  contra-indications.  But  the  injuri- 
ous action  may  be  made  useful,  if  directed  toward  the  excess  of  assimila- 
tive force,  or  more  often,  the  want  of  proportion  between  a  defective 
disassimilation  and  an  excessive  nutrition,  which  produces  obesity  or 
polysarcia;  and  it  certainly  would  not  be  impossible  to  equalize  these 
forces  to  some  extent  by  the  prudent  and  continued  use  of  astringent 
tonics. 

Having  now  examined  in  a  general  way  the  indications,  if  we  attempt 
to  draw  the  conclusions  which  they  involve  in  regard  to  pathology  and 
general  therapeutics,  we  shall  be  struck  with  the  following  considerations, 
which  the  reader  will  easily  develop  without  our  aid. 

The  astringent  tonics  contract,  condense,  tan  the  tissues,  and  dissi- 
pate their  moisture.  Another  class  of  remedies  is  exactly  the  opposite 
in  its  effects,  namely,  the  emollient  or  atonic  remedies,  which  relax,  soften 
the  tissues,  and  make  moisture  predominate  in  them.  Now,  suppose  for 
an  instant  that  our  therapeutical  resources  were  limited  to  these  two 
classes,  tonics  proper,  and  atonies  or  emollients,  what  would  be  their 
poverty,  and  how  many  the  indications  beyond  those  which  these  two 
classes  are  fitted  to  fulfil  !  They  are  the  two  with  which  practical  medi- 
cine could  dispense  the  most  easily;  they  are  hardl}^  more  than  adju- 
vants or  palliatives  when  associated  Avith  treatment.  Let  it  be  remarked 
that  we  do  not  mean  to  speak  of  the  remedies  which  produce  indirectly 
these  two  opposite  states,  the  strictum  and  the  laxum,  but  of  those  which 
produce  them  immediately.  We  do  not  refer  to  bloodletting,  purging, 
etc.,  which  remotely  produce  atony,  nor  to  iron,  analeptics,  gymnastics, 
etc.,  which  remotely  produce  tonicity;  for  we  might  in  this  way  reduce 
all  treatment  to  the  definitive  production  of  these  two  organic  conditions. 
We  speak  only  of  agents  which  cause  them  by  a  peculiar  and  characteris- 
tic action. 

The  hypothesis  being  thus  restricted,  who  does  not  see  that  therapeu- 
tics would  be  disarmed  in  presence  of  ninety-nine  of  every  hundred  dis- 
eases, and  could  lend  no  real  aid  except  in  a  few,  and  that,  even  in  these, 
they  would  sometimes  have  to  leave  untouched  true  indications?  What 
sterility  and  falsehood  would  invade  those  systems  of  medicine  which 
should  adopt  as  their  physiological  basis  this  fictitious  dichotomy,  which 


I 


ASTRINGENTS.  113 

should  have  formed  all  etiology  and  pathology  upon  the  pure,  unique, 
and  essential  lesions  of  these  two  states  of  the  living  solids,  and  should 
reject  all  remedies  but  those  suited  to  contract  or  relax  the  fibre — tonics 
and  emollients  ! 

And  yet,  it  is  within  this  narrow  sphere,  this  niggardly,  inadequate 
therapeutics,  superficially  modified  by  the  different  medical  epochs,  that 
all  the  exclusive  solidists  for  the  last  two  thousand  years  have  been  re- 
volving !  From  Asclepiades  to  Ccelius  Aurelianus,  the  strictum  and  the 
laxum;  later,  excess  or  defect  of  irritability,  tension  and  relaxation,  spasm 
and  atony,  sthenia  and  asthenia,  the  stimulus-diathesis  and  contro-stimu- 
lism,  irritation  and  abirritation,  excitation  and  paralysis  of  vaso-motor 
nerves,  have  only  changed  their  form  in  passing  through  the  systems  of 
Glisson,  Baglivi,  Hoffmann,  Haller,  Cullen,  Brown,  the  school  of  Rasori, 
and  the  physiological  school.  It  is  true  that  immense  progress  has  been 
made  from  Themison  to  Broussais  and  his  successors,  and  that  ideas  have 
grown  less  coarse,  and  larger  and  more  physiological.  "  Themison,"  as 
the  immortal  author  of  the  "  Examen  des  doctrines"  very  well  says 
("Ex.  des  doctr.,"  t.  I.,  p.  112),  ''did  not  calculate  the  sum  of  the  vital 
forces;  he  did  not  rise  to  that  generalization  of  modern  vitalism;  he  saw 
only  the  pores,  and  in  general  all  the  openings  of  the  exterior  of  the 
body,"  etc.  Yes;  but  it  is  proper  to  add  that,  excepting  anatomical 
details  which  at  that  date  were  impossible,  Coelius  Aurelianus  left  almost 
no  fundamental  detail  for  Broussais  to  discover.  But  Broussais  did  not 
know  this;  and  the  public  might  have  been  yet  more  learned,  without 
detracting  from  Broussais'  celebrity,  and  with  no  less  glorification  of  his 
errors  on  the  part  of  the  medical  world. 

It  is  nevertheless  certain  that  all  these  systems,  in  their  native  purity, 
and  remaining  true  to  their  principles,  are  forced  to  reject  the  most  pre- 
cious observations  of  the  clinic,  and  a  great  many  of  the  best  attested 
remedies.  The  exclusive  solidist  ought  not  to  pay  attention  to  the  primi- 
tive morbid  change  of  the  liquids,  the  special  course  which  this  condition 
gives  to  disease,  and  the  resultant  modifications  in  therapeutics;  he  must 
reject  the  specific  nature  of  disease,  and  with  it  the  specific  remedies;  he 
must  admit  only  the  path  of  a  vague  and  indeterminate  sympathy  in 
explaining  general  affections,  the  simultaneous  or  successive  occurrence 
of  morbid  symptoms;  he  must  see  only  quantities  and  never  different 
qualities  in  disease;  in  a  word,  he  must  despise  all  the  precious  observa- 
tions and  precepts  which  have  been  stored  up  by  the  physicians  of  the 
Hippocratic  line.  Remark,  therefore,  that  the  exclusively  solidist  schools 
have  been  able  to  furnish  men  of  great  talent,  illustrious  writers,  but  not 
such  as  deserve  to  be  called  profound  observers,  consummate  practition- 
ers, and  whose  works  are  beyond  the  outrages  of  time  and  systems. 

As  the  therapeutic  agencies  which  act  only  on  the  living  solid  to  in- 
crease or  relax  its  tonicity  have  a  very  limited  range,  and  are  often  dan- 
gerous, since  in  general  (except  in  the  simple  cases  which  we  distin- 
guished above)  they  attack  only  the  external  manifestation  of  the  disease, 


114  THERAPEUTICS. 

and  leave  the  cause  or  generative  condition  in  all  its  morbific  povper;  so 
are  the  systems  of  medicine  which  rest  on  exclusive  solidism  insufficient 
and  dangerous,  since,  in  a  very  large  number  of  cases,  they  see  and 
attack  only  the  external  acts  or  the  symptoms  which  the  solids  alone  are 
able  to  manifest,  and  leave  the  principles  or  causes  in  all  their  morbific 
intensity. 

It  is  superfluous,  we  think,  to  give  proofs  of  these  assertions;  any  one 
may  easily  supply  them.  What  we  have  said  of  the  topical  indications 
and  contra-indications  of  the  astringent  tonics  may  lead  the  way  to  these 
arguments,  as  numerous  as  they  are  incontestable. 


CHAPTER  m. 

ALTERATIVES. 

Mercury. 

Therapeutic  Action. 

The  topical  action  of  mercury,  as  we  shall  see  further  on,  renders  it 
one  of  the  most  potent  of  substitutive  agents.  Our  attention  will  first 
be  directed  to  mercury  as  a  general  agent,  and  the  topical  action  will  be 
described  at  a  later  point. 

Mercury  in  Syphilis. 

Infecting  chancre. — A  leadi^ng  characteristic  of  this  disease  is  its  period 
of  incubation,  the  duration  of  which  averages  twenty-six  days.  It  is, 
therefore,  not  open  to  the  ectrotic  method  advised  by  Ricord,  which  con- 
sists in  killing  immediately,  by  an  energetic  cauterization,  every  chancre 
which  has  not  passed  the  fifth  day  after  contagion.  If  the  chancre  is 
mixed,  that  is,  has  at  first  the  marks  of  simple  chancre  and  becomes  indu- 
rated later,  Ricord's  practice  presents  no  inconvenience,  though  the 
chances  of  arresting  infection  are  quite  small.  We  consider  the  infect- 
ing chancre  as  the  first  manifestation  of  general  infection ;  it  not  only 
requires  treatment  like  any  ulcer,  but  imposes  the  duty  of  deciding  whe- 
ther mercurial  treatment  must  be  used. 

We  ought  to  remember  that  indurated  chancre  may  readily  get  well 
without  treatment,  leaving  no  cicatrix.  There  is  then  no  immediate  need 
of  mercury;  it  is  required  for  the  future.  Experience,  however,  shows 
that  feeble  caustics  containing,  for  instance,  acid  nitrate  of  mercury,  or 
sublimate,  may  improve  a  chancre  which,  under  a  non-specific  treatment, 
becomes  excessively  chronic  or  is  agsrravated. 

Grant,  as  we  must,  that  these  primary  symptoms  recover  without  mer- 
cury: the  question  remains — Is  consecutive  syphilis  more  common  when 
the  primary  symptoms  have  been  treated  with  mercury  than  when  not? 
Facts  are  invoked  on  both  sides  by  the  partisans  of  the  new  and  the  old 
theory;  both  have  published  statistics,  which  have  been  charged  with 
falsehood;  and  in  the  midst  of  this  conflict  we  can  hardly  take  any  other 
ground  than  that  of  the  immense  majority  of  physicians,  who  always  di- 
rect mercurial  treatment  for  patients  who  have  had  syphilitic  symptoms; 
no  matter  whether  these  have  disappeared  or  not,  under  the  influence  of 


116  THERAPEUTICS. 

simple  and  non-specific  treatment,  provided  the  induration  of  tlie  pri- 
mary chancre  has  been  well  attested.  This  treatment,  if  methodically  and 
prudently  conducted,  never  causes  inconvenience,  and  we  do  not  see 
why  a  precaution  should  not  be  taken,  the  omission  of  which  might  be 
fatal. 

8y2')hiUtic  infection. — When  consecutive  and  constitutional  syphilis 
appears,  mercury,  though  not  infallible,  has  so  evident  a  power  that  an 
inconceivable  blindness  is  required  in  order  not  to  see  it.  In  this  case 
the  treatment  should  be  long  continued,  and  the  general  hj^gienic  precau- 
tions which  are  proper  in  venereal  disease  are  absolutely  indispensable 
here. 

Two  methods  dispute  the  precedence  in  the  treatment  of  syphilis  by 
mercury.  In  tlie  one,  the  doses  are  diminished,  the  intervals  increased, 
and  salivation  is  never  produced;  sudorifics  and  depuratives  are  used  at 
the  same  time;  treatment  is  kept  up  till  the  symptoms  of  s\^philis  are  all 
gone,  though  from  time  to  time  it  must  be  suspended  to  give  the  system 
rest,  and  to  let  it  recover  susceptibility  to  the  action  of  the  medicine. 
When  all  the  symptoms  of  syphilis  are  past,  treatment  is  insisted  upon  for 
a  month  or  two  longer,  and  then  stopped. 

This  plan  is  called  the  method  of  extinction,  or  method  of  Montpellier; 
not  that  it  perfectly  agrees  with  that  which  Ilaguenot  first  recommended 
by  this  name,  but  as  preserving  its  spirit  and  tendency. 

The  other  metliod  consists  in  giving  mercury  externally,  internally, 
or  in  both  ways,  to  produce  rapid  salivation;  this  is  the  method  of  Boer- 
haave,  or  that  of  saturation. 

The  latter  is  certainly  the  more  active  and  efficient,  but  it  requires 
numberless  hygienic  precautions  and  a  severe  regimen,  which  patients  do 
not  like.  It  is  preferred,  and  always  should  be  preferred  in  special  hos- 
pitals, where  strict  watch  and  discipline  are  possible;  but  elsewhere  the 
method  of  Montpellier  has  prevailed,  as  being  easier  to  follow,  more  con- 
venient, not  exacting  in  its  regimen,  and  not  requiring  a  change  in  habits 
which  might  attract  attention.  Physicians,  in  spite  of  themselves,  give 
up  a  method  which  they  think  the  best,  and  by  this  disgraceful  conces- 
sion, assuredly  cause  the  grave  consecutive  accidents  which  we  have  to 
lament  daily. 

The  following  is  Boerhaave's  method  of  obtaining  salivation: 

14G8.  To  procure  it,  drench  the  patients  for  several  days  with  large 
quantities  of  ptisan. 

14G9.   Next  give  a  small  dose  of  calomel  every  two  hours. 

1470.  When  the  breath  begins  to  be  fetid,  the  gums  are  painful,  the 
teeth  seem  to  grow  longer,  examine  whether  it  be  proper  to  continue,  to 
stop,  or  to  check  the  symptoms. 

1471.  A  salivation  of  three  or  four  pounds  a  day  is  enough. 

1472.  If  less,  it  must  be  excited  by  mercury. 

1473.  If  more  abundant,  it  must  be  restrained  by  emollient  clysters, 
purges,  sudorifics. 


ALTERATIVES.  117 

1474.  If  mercury  attacks  the  bowels,  opium  and  sudorifics  are  indi- 
cated. 

1475.  If  the  throat,  mouth  and  gums  are  too  swollen  and  painful,  give 
remedies  as  indicated  in  aphorism  1473,  and  softening  gargles  or  colluto- 
ries. 

1476.  This  treatment  should  be  kept  up  till  the  symptoms  have  en- 
tirely ceased,  usually  thirty-six  days. 

1477.  Afterwards,  for  thirty-six  days  more,  give  only  very  moderate 
doses  of  mercury,  to  maintain  a  slight  salivation. 

These  rules  are  still  followed  by  some  in  very  severe  and  obstinate 
cases,  when  the  patients  consent.  As  regards  the  choice  of  mercurial 
preparations,  however,  and  the  mode  of  administration,  there  is  a  disa- 
greement among  his  followers.  Some  rub  in  mercurial  ointment  upon 
the  thighs,  arms,  axillae,  genitals;  others  prefer  sublimate  baths  after  the 
method  of  Wedekind  and  Recamier;  some  fumigate  with  cinnabar  in  an 
apparatus  which  leaves  the  head  out;  others  prefer  internal  treatment, 
and  give,  following  Boerhaave's  example,  calomel,  or  blue  mass;  but  the 
most  renowned  of  the  internal  remedies  are  sublimate  and  the  iodides,  the 
former  introduced  by  Van  Swieten,  the  latter  chiefly  by  Biett  and  the 
French  physicians  of  our  century. 

Richard  Wisemann  was  the  first  to  use  corrosive  sublimate  internally; 
he  never  gave  it  alone,  David  Turner,  in  1717,  gave  it  dissolved  in 
brandy,  and  about  the  same  time  it  was  used  in  the  Palatinate  as  advised 
by  Brunner.  But  the  praises  of  Van  Swieten  procured  an  extraordinary 
reputation  for  this  remedy.  By  his  orders,  it  was  used  in  all  the  Austrian 
armies  for  the  treatment  of  venereal  disease;  but  Brambilla  states  that 
the  surgeons,  convinced  of  its  uncertainty  and  its  danger,  secretly  em- 
ployed calomel  while  lavishing  extravagant  praises  on  the  remedy  pre- 
scribed by  government  (Sprengel:  "Hist,  de  la  med.,"  t.  V.,  p.  518). 
The  severe  and  inappropriate  measures  taken  by  Van  Swieten  to  force 
■  his  confreres  to  use  his  favorite  remedy  made  many  enemies  for  it,  who 
exaggerated  its  dangers;  but,  in  spite  of  these  violent  quarrels  (Stoerck: 
Ann.  med.,  t.  II,,  p.  215),  Van  Swieten's  solution  and  pills  of  sublimate 
were  soon  introduced  into  all  the  military  hospitals;  and  at  this  day,  subli- 
mate forms  the  basis  of  the  pills  and  solutions  given  by  the  wretches  who 
feed  on  the  credulity  of  patients  by  praising  their  "treatment  without 
mercury." 

For  some  years  past,  protiodide  of  mercury  has  been  substituted  for 
sublimate  and  frictions  with  ointment  in  constitutional  syphilis.  The 
remedy  is  certainly  powerful,  but  ought  not,  perhaps,  so  entirely  to  ex- 
clude other  remedies  in  secondary  disease. 

Syphilis  analyzed. — 8yphilid(s. — Cutaneous  syphilis  affections  are 
divided  into  two  classes.  One,  resolutive  or  benign,  is  usually  precocious, 
and  may  disappear  without  treatment;  the  other,  ulcerous  or  malignant, 
is  tardy;  the  latter  is  the  one  usually  treated  with  mercurials,  and  the 
less  mercury  has    been    previously  taken,    the    more   active    this  treat- 


118  THERAPEUTICS. 

ment.  The  most  active  preparations  are,  therefore,  reserved  for  this 
class. 

Syphilitic  affections  of  the  mouth  and  throat. — Mercury,  which  so 
easily  affects  the  mouth,  is  much  less  successful  in  syphilitic  disease  of 
this  part  than  in  the  syphilidae. 

M.  Crequy  has  invented  a  very  efficient  treatment  for  these  troubles, 
consisting  of  pastilles,  made  by  the  following  formula: 

Protiodide  of  mercury 0'05  =  gr.  0'77 

lodate  of  potassium 005=gr.  0'77 

Chlorate  of  potassium 0"20  =  gr.  3"1 

Sugar 1-     =;gr.  15' 

Gum    tragacanth,    and    orange-flower   water    suffi- 
cient to  make  a  mucilage q.  s. 

Essence  of  citron  or  mint one  drop. 

Carmine  to  color q.  s. 

Make  a  pastille  of  about  30  grains;  one  or  two  to  be  taken  daily. 

This  preparation  has  several  advantages.  Its  nature  is  not  suspected 
— it  is  really  a  secret  remedy.  It  has  also  the  advantage  that,  in  moving 
about  in  the  mouth,  the  remedy  is  made  to  touch  the  sores,  and  a  part  is 
absorbed  through  them.  Then  the  addition  of  chlorate  of  potassium 
enables  the  remedy  to  be  borne  as  long  as  necessary.  Our  own  experi- 
ence is  most  favorable.  We  have  cured  with  this  remedy  syphilids  of 
the  mouth  and  throat  which  had  resisted  ordinary  treatment  and  were 
desperately  obstinate.  We  have  had  encouraging  results  in  circumscribed 
tuberculous  syphilidre,  a  slow  and  tenacious  form.  We  had  supposed 
that  the  efficacy  of  these  pastilles  was  due  to  the  formation  of  a  double 
iodide  by  contact  with  the  saliva  or  gastric  juice,  but  a  solution  made  and 
analyzed  by  M.  Lefort,  who  is  a  very  competent  authority,  shows  that  no 
decomposition  takes  place  in  water. 

SyiyhiUs  of  the  boties,  tendons  and  nmscles. — Here  mercury  is  gener- 
ally inefficient,  while  iodide  of  potassium  has  a  heroic  action,  especially 
in  the  case  of  bone.  It  is  not  quite  so  with  muscular  tumors,  which  we 
have  seen  appearing  in  company  with  tardy  syphilidre  and  yet  recover, 
as  if  by  enchantment,  under  the  influence  of  emplastrum  de  Vigo  asso- 
ciated with  internal  mercurial  treatment.  • 

Visceral  syphilis  and  syphilitic  affections  of  nerves. — Here  iodide  of 
potassium  has  very  little  action,  and  mercury,  especially  as  given  by 
Boerhaave's  method,  must  be  preferred. 

Hereditary  and  congenital  syphilis. — What  is  to  be  done  with  a  child 
that  is  born  with  the  usual  signs  of  hereditary  syphilis?  The  affection 
is  so  grave  and  fatal,  that  some  practitioners,  as  M.  Roger  (Societe  medi- 
cale  des  hopitaux,  1865),  think  it  useless  to  begin  treatment.  Yet  if  we 
have  any  reason  to  hope  that  the  child  can  resist,  we  must  treat,  but  with 
small  doses. 


ALTEKATIVES.  119 

A  child  born  of  parents  who  are  clearly  syphilitic,  does  not  usually 
have  signs  of  infection  upon  him  at  birth.  We  tliiiik  it  useless  then  to 
employ  specific  treatment,  which  we  reserve  till  symptoms  appear.  The 
thing  to  be  insisted  on  is,  that  the  mother  shall  suckle  the  child  herself, 
and  not  give  it  to  a  nurse,  since  a  sore  in  the  mouth  might  escape  obser- 
vation, and  infect  the  nurse,  when  the  physician  would  be  responsible  to 
a  certain  extent.  If  the  child  must  be  given  to  a  nurse,  the  latter  must 
be  told  not  to  give  suck  except  by  means  of  an  artificial  nipple. 

When  the  symptoms  appear,  mercury  must  be  the  basis  of  treatment. 
The  substitutes  are  impracticable  for  the  infant.  We  continue  to  prefer 
the  liquor  of  Van  Swieten,  in  the  dose  of  1  or  3  grammes  (gr.  15- — 30)  a 
day  with  milk;  but  this  sometimes  causes  or  keeps  up  diarrhoea,  and  has 
to  be  abandoned  for  a  short  time. 

Calomel,  even  associated  with  chlorate  of  potassium,  and  protiodide 
have  few  partisans.  Mercurial  inunction  has  disadvantages  connected 
with  the  intestine,  and  others. 

The  first  indication  is  to  take  care  of  the  infant's  skin  and  extinguish 
the  symptoms  as  soon  as  possible. 

Of  all  remedies,  we  do  not  know  one  comparable  to  the  baths  and 
solutions  of  sublimate.  The  solution  of  bichloride  of  mercury  in  water, 
by  the  aid  of  alcohol  or  muriate  of  ammonia,  has  the  immense  advantage 
that  it  can  be  graduated  according  to  circumstances,  from  the  slightly 
caustic  solution  to  that  which  causes  no  perceptible  sensation.  For  a 
child's  bath  we  never  use  more  than  one  gramme  of  sublimate.  The  child 
tolerates  the  bath  almost  as  well  as  the  adult,  and  it  would  be  bad  prac- 
tice always  to  reduce  the  solution  to  the  degree  prescribed  by  all  formu- 
laries. When  the  skin  is  cured,  though  the  syphilis  be  not  cured,  the 
cachectic  debilitated  child  may  be  unable  to  derive  nutriment  enough 
from  the  breast,  wlien  tonic,  gelatinous,  aromatic,  salted,  sulphurous 
baths  will  supply  resources  which  internal  medicine  does  not  yield.  But 
this  class  of  remedies  is  inapplicable  except  when  they  act  upon  a  sound 
skin. 

Diet,  in  infantile  syphilis,  is  the  first  of  adjuvants,  if  not  of  medicines. 
The  mother  must  nurse  the  child  when  possible,  and  take  Van  Swieten's 
liquor,  which  should  always  be  prescribed  ("Clinique  medicale  de  I'Hotel- 
Dieu,"  2e.  edit.,  t.  III). 

Forms  of  syphilis. — When  a  person  in  apparently  sound  health  is  af- 
fected, the  pathological  tendencies  of  the  organism  usually  come  to  light 
and  give  to  syphilis  a  special  aspect  and  course.  This  is  why  scrofulous 
persons  have  ulcerative  and  suppurative  syphilis  more  frequently  than 
others,  the  gouty  have  tuberculous  syphilidae,  and  the  dartrous  moist  and 
intractable  syphilidfe.  We  must  never  forget  to  unite  to  the  mercurial 
treatment  a  regimen  suited  to  the  patient's  constitution;  as,  otherwise, 
the  therapeutic  effect,  as  distinct  from  the  physiological  and  toxic,  will 
not  be  developed. 

Finally,  extreme  heat  or  cold  of  climate  is  bad  for  syphilitic  patients; 


1 20  THERAPEUTICS. 

and,  in  obstinate  cases,  it  may  be  well  to  send  them  to  the  temperate  cli- 
mates bordering  on  the  Mediterranean. 

Duration  of  treat  mod. — In  what  dose  should  mercury  be  used  to  de- 
stroy a  constitutional  syphilitic  disorder  ?  A  categorical  reply  is  impos- 
sible. In  Boerhaave's  method,  the  proper  dose  is  that  which  produces  the 
effects  which  he  requires.  In  the  method  by  extinction,  the  proper  dose 
will  be  such  as  causes  the  syphilitic  symptoms  to  disappear.  It  is  impos- 
sible to  say  anything  more  exact,  and  for  the  following  reason. 

Salivation  sometimes  occurs  during  inunction  with  mercurial  ointments, 
so  that  it  can  be  performed  only  once  a  week,  in  order  to  keep  the  saliva- 
tion at  that  moderate  degree  required  by  Boerhaave.  In  this  case  15 
grammes  (230  grs.)  of  the  ointment  will  suffice  for  treatment.  At  other 
times,  to  obtain  the  same  effect,  twenty,  thirt}^  even  a  hundred  frictions 
of  8  grammes  (  3  ii.)  will  be  required,  making  750  grammes  (188  drachms) 
of  ointment.  One  is  suitably  affected  by  sublimate  given  in  the  dose  of 
1  or  2  milligrammes  (gr.  0'015 — O'Oo),  another  will  bear  25  milligrammes 
morning  and  evening,  and  will  have  to  continue  its  use  two  or  three 
months. 

The  same  is  true  with  the  method  of  extinction. 

The  physiological  law  is  perfectly  applicable  here,  that  one  is  nourished 
by  what  one  digests,  not  what  one  eats.  In  tlierapeutics,  we  may  say  that 
the  patient  is  cured,  not  by  what  he  takes,  but  by  what  is  absorbed.  For 
reasons  impossible  to  estimate,  the  system  may  absorb  only  an  atom  of 
mercury  when  enormous  doses  are  offered  to  the  absorbent  surfaces,  while 
minimal  doses  are  absorbed  wholly.  It  is  further  necessary,  in  order  that 
mercury  shall  be  of  use,  that  it  should  produce  its  alterant  effects;  we 
cannot  deny  that  the  system  very  often  resists  the  toxic  action  of  the  drug, 
and  requires  proportionately  large  doses. 

Mercury  has  been  recommended  as  a  preventive  of  syphilis.  Falck 
("Treatise  on  the  Venereal  Diseases,"  London,  1771)  and  W.  Harrison 
("Diss,  de  lue  venerea,"  Edinb.,  1781)  said  that  this  end  might  be  accom- 
plished by  having  the  loins  rubbed  with  mercurial  ointment  before  coitus. 
L.  Warren  caused  the  glans  to  be  rubbed  with  it  ("  Nouvelle  methode  pour 
guerir  la  gonorrhce  virulente,"  Amsterdam,  1771).  Assalini  caused  fric- 
tions with  calomel  and  saliva  to  be  made  in  tlie  hollow  of  the  hand  or  on 
the  penis  ("  Essai  medical  sur  les  vaisseaux  lymphatiques,  etc.,"  Turin, 
1787).  Guilbert  de  Preval  had  the  genital  parts  washed  with  eau  phage- 
denique  before  and  after  connection  ("  Examen  de  Feau  fondante  "  de  M. 
Guilbert,  etc.,  Paris,  1777).  J.  Hunter  had  urethral  injections  made  after 
the  act,  with  a  weak  solution  of  sublimate  in  distilled  water,  5 — 10  centi- 
grammes of  dento-chloride  of  mercury  to  250  grammes  of  water  (gr.  0*8 — 
gr.  1*5  to  3  viii.).      ("  Treatise  on  the  Venereal  Diseases,"  London,  1786.) 

We  are  not  sure  that  all  these  plans  are  as  valuable  as  they  claim  to 
be;  the  anointing  with  fats  before  coitus  may  have  a  mechanical  preserv- 
ative action  like  that  of  a  condom;  lotions,  of  whatever  nature  they  be, 
made  after  an  impure  connection,  may  prevent  the  virus  from  remaining 


ALTERATIVES.  121 

in  contact  with  the  genital  parts;  but  evidently  we  should  not  be  in  haste 
to  infer  the  preservative  action  of  mercurials,  nor  should  we  attach  much 
importance  to  that  very  apocryphal  experiment  of  Harrison's  (loc  cit.), 
who,  having  mixed  syphilitic  pus  with  a  mercurial,  proved  the  innocuous- 
ness  of  the  mixture  by  repeated  inoculations  (see  Gmelin:  "  App.  med.," 
t.  VITI.,  pp.  28,  29).  Do  we  not  know  that  M.  Ricord  has  destroyed  the 
poison  of  chancre  by  mixing  it  with  a  great  many  cliemical  agents  very 
unlike  mercury  ? 

We  are  absolutely  ignorant  of  what  mercury  could  do  if  given  as  a  pre- 
ventive, though  we  might  very  easily  learn.  There  are  certain  industries 
where  mercury  is  handled;  the  workmen  are  constantly  impregnated 
with  it  ;  it  would  be  curious  to  know  whether  syphilis  is  more  or  less 
severe  among  these  than  among  others,  or  whether  it  is  modified  in  any 
way. 

Peritonitis. — Antiphlogistic  treatment,  usually  so  efficient  in  phleg- 
masi<e  of  the  serous  membranes,  is  usually  powerless  in  puerperal  peritoni- 
tis and  acute  hydrocephalus.  A  treatment  is  required  which  is  powerful 
enough  to  quench  the  inflammation  suddenly.  Mercurials  in  large  doses 
have  seemed  to  fulfil  this  end,  at  least  for  peritonitis,  if  we  are  to  believe 
the  numerous  testimonies  of  recent  years.  The  popularity  of  the  method 
is  due  to  M.  Velpeau.  No  doubt,  calomel  and  mercurial  friction  had  been 
used  long  before  his  time  in  peritonitis  and  a  multitude  of  other  inflamma- 
tions; \  andezande  used  calomel  and  frictions,  but  relied  chiefly  on  calo- 
mel and  opium,  and  used  frictions  only  secondarily,  applying  them  once 
or  twice  a  day  to  the  thighs,  and  only  when  he  could  not  give  the  proto- 
chloride  internally.  Laennec  used  friction,  but  chiefly  in  chronic  perito- 
nitis. Chaussieur  used  them  in  puerperal  peritonitis,  but  weakly  and  un- 
methodically. Yelpeau,  on  the  contrary,  endeavored  to  procure  the  im- 
mediate absorption  of  very  large  doses  of  mercury,  so  as  to  produce  mer- 
curial cachexia  as  quickly  as  possible.  In  this  way  he  sought  to  bring 
the  blood  in  a  few  hours  into  such  a  state  that  it  would  be  unfit  to  nour- 
ish a  severe  inflammation;  and  this  seemed  the  more  necessary  to  him,  as 
in  puerperal  peritonitis  the  inflammation  makes  such  fearfully  rapid  prog- 
ress. He  gave  the  drug  in  all  forms  and  in  enormous  doses;  by  friction 
upon  the  bowels  and  thighs  at  once,  simultaneously  with  the  internal  use 
of  calomel,  so  as  to  produce  a  profound  mercurial  infection  instantly  (en 
peu  d'instants).  He  continued  the  treatment  until  signs  of  saturation  of 
the  system  occurred,  that  is,  swelling  of  the  gums  and  abundant  salivation. 
Velpeau's  first  observations  were  published  in  the  Revue  medicale,  Janu- 
ary, 1827;  but  the  paper  printed  by  him  two  years  later,  in  the  Archives 
gen'erales  de  m'edecine,  t.  XIX.,  p.  535,  placed  the  mercurial  treatment  at 
the  head  of  those  which  succeeded  in  many  epidemics.  We  say,  in  many 
epidemics;  for  in  some  it  fails.  M.  Tonnele,  in  a  memoir  printed  a  few 
years  later  in  the  ^rc/a'ues,  showed  that  frictions,  in  the  hands  of  the  phy- 
sicians of  the  Maternite,  had  not  proved  as  successful  as  with  M.  Velpeau. 
In  certain  epidemics  of  puerperal  fever,  the  course  is  so  rapid  that  death 
6 


122  THERAPEUTICS. 

occurs  in  a  few  hours.  Of  course,  under  such  circumstances,  no  treatment 
can  be  of  use,  not  even  the  most  active  and  powerful. 

To  apply  mercurial  treatment  in  peritonitis  mildly,  Avould  be  to  mis- 
take the  nature  of  that  treatment.  When  once  the  inflammatory  products 
have  been  allowed  to  be  effused  into  the  peritoneal  sac,  the  value  of  the 
remedy  becomes  extremely  doubtful.  It  is  as  with  bleeding-;  all  does  not 
depend  on  giving-  mercury  and  drawing  blood,  but  on  doing  these  to  the 
proper  extent  in  the  right  way. 

The  doses  of  mercurial  ointment  used  b}^  M.  Velpeau  to  produce 
prompt  salivation  varied  from  30  to  GO  grammes  daily  (nearly  5  i. — ii.). 
We  have  been  bolder,  and  have  habitually  prescribed  it  in  the  dose  of 
100,  and  even  150  grammes  (nearly  3  iii. — v.)  in  the  24  hours,  while 
M.  Paul  Dubois  did  not  fear  to  use  from  500  to  750  grammes  (nearly 
3  xvi. — XX i v.)  daily. 

We  can  pardon  excess  in  the  presence  of  such  imminent  danger  ;  but 
it  must  be  confessed  that  such  active  treatment  has  its  inconveniences. 
As  soon  as  salivation  occurs  it  is  certainly  desirable  to  stop,  but  the  mer- 
cury already  covers  the  skin,  soils  the  clothes  and  the  bed,  and,  in  spite 
of  the  minutest  pains,  absorption  must  continue  for  some  days  longer. 
Mercurial  intoxication  makes  rapid  progress;  and  it  is  then  that  severe 
lesions  of  the  mouth  occur,  besides  those  severe  general  eczematous  erup- 
tions which  are  so  well  described  by  Alley,  and  those  gangrenous  inflam- 
mations of  the  genitals  which  are  mentioned  by  Paul  Dubois. 

It  is  here  that  Law's  method  finds  application.  [Hourly  doses  of  gr, 
C'064  of  calomel  in  pill;  salivation  produced  in  from  24  to  48  hours. — 
Traiisl.]  In  this  method  calomel  produces  salivation  nearly  as  soon,  and 
quite  as  surely  as  the  most  copious  inunctions;  and  as  soon  as  salivation 
is  produced,  we  have  the  power  to  stop  instantly  the  administration  of 
what  is  sometimes  so  pernicious  a  poison.  For  more  than  fifteen  years 
we  have  substituted  Law's  method  for  the  frictions  with  large  quantities 
of  ointment  of  which  we  were  formerly  the  zealous  partisans;  we  have 
always  obtained  the  effect  which  we  had  formerly  secured  by  frictions, 
and  this,  not  only  without  inflicting  fatigue  and  risk  upon  the  patient, 
but  without  inconvenience  to  the  nurses. 

Acute  hydrocephalus. — It  is  very  rare  that  recovery  takes  place  from 
this  affection — acute  and  simultaneous  inflammation  of  the  meninges  and 
the  brain — either  in  a  child  or  in  an  adult.  It  is  the  locality,  not  the  ex- 
tent, that  makes  it  so  dangerous.  As  soon  as  our  diagnosis  is  positively 
made,  the  nervous  pulp  is  already  on  the  point  of  disorganization;  and, 
however  active  may  be  our  treatment,  it  still  fails,  to  the  despair  of  phy- 
sicians and  the  family.  The  mercurials,  both  internally  and  externally 
used,  have  been  advised  as  in  peritonitis,  but  with  less  success,  for  the 
uncertainty  of  the  diagnosis  destroys  much  of  the  practical  interest  of 
the  observations,  numerous  as  they  are,  published  by  Percival,  Delpech, 
Major,  and  others.  M.  Liegeard  {Bull,  de  therap.,  t.  VII.,  1834)  and 
Beid  Clanny  {Journ.  des  conn,  med.-chir.,  nov.,  1836)  have  since  pub- 


ALTERATIVES.  123 

lished  new  cases  of  the  use  of  mercurials  in  acute  hydrocephalus;  the 
latter  insists  much  on  the  point,  that  too  much  mercury  cannot  be  ab- 
sorbed, nor  too  quickly,  and  gives  internal  doses  of  calomel  which  to  most 
physicians  are  frightful,  but  which  cease  to  be  such  when  we  faithfully 
and  impartially  examine  his  reasons  for  giving  such  doses.  He  remarked 
that  almost  all  the  calomel  which  he  gave  was  found  in  the  stools  of  the 
patients,  so  that  when  GO  centigrammes  (gr.  9'2)  were  given,  not  one 
centigramme  was  absorbed;  he  therefore  thought  that  he  might  increase 
and  repeat  the  doses,  and  gave  from  4  to  8  grammes  (  3  !• — ii-)  of  calomel 
daily,  whereby  he  made  the  system  absorb  speedily  a  dose  of  mercury  ca- 
pable of  acting  powerfully  on  the  system.  Since  adopting  this  system,  he 
has  found  hydrocephalus  much  less  to  be  dreaded;  and  whereas  he  formerly 
lost  almost  all  his  cases,  he  now  considers  the  disease  readily  conquerable. 

Whatever  confidence  we  may  have  in  the  method  and  the  assertions 
of  Beid  Clanny,  we  confess  that  we  shall  hesitate  to  accept  his  results 
until  we  have  seen  similar  success.  In  several  cases  of  meningo-enceph- 
alitis  we  have  used  his  method  without  success,  though  we  applied  it 
with  an  energy  which  our  author  must  have  approved  of. 

We  have  used  Law's  method  also  without  success,  in  this  terrible  dis- 
ease, continuing  the  calomel  not  for  two,  but  eight  days  in  succession.  We 
have  rarely  obtained  salivation;  but  even  when  the  gums  were  severely  in- 
flamed, the  disease  nevertheless  went  straight  on  to  its  fatal  termination. 

The  inadequacy  of  mercurial  treatment  in  the  encephalo-meningitis 
of  children  furnishes  no  argument  against  its  general  efficacy.  Death  is 
almost  certain  in  acute  hydrocephalus,  whatever  we  may  do.  We  have 
grown  old  in  practice,  we  have  long  been  at  the  head  of  a  hospital  for 
children;  but  we  confess  with  pain  that  we  can  scarcely  number  one  or 
two  cases  in  which  we  have  seen  a  child  recover  from  a  cerebral  fever. 

Acute  synovial  rheumatism. — The  rapid  and  favorable  effects  of  mer- 
cury in  peritonitis,  the  most  fearful  of  serous  phlegmasia,  suggested  to 
us  the  idea  of  employing  it  in  acute  articular  rheumatism.  We  have  thus 
treated  fourteen  cases,  in  which  the  fever  was  very  high  and  a  great  many 
joints  were  attacked.  In  six,  the  cure  was  extraordinarily  rapid;  but  in 
the  other  eight  the  disease  went  on  as  if  nothing  had  been  done.  The 
pain,  however,  was  less  severe,  and  we  thought  the  cardiac  complications 
were  less  frequent.  Here,  as  in  peritonitis,  we  caused  ointment  to  be 
rubbed  in  upon  the  belly  and  thighs — from  20  to  60  and  120  grammes 
daily  (  3  v.,  xv.,  xxx.)  until  the  gums  swelled,  v^hich  usually  occurred  at  the 
end  of  the  second  day  or  the  beginning  of  the  third.  We  then  ceased, 
and  confined  our  care  to  the  maintenance  of  a  mild  temperature  and  the 
administration  of  emollient  drinks.  In  the  hospitals  this  treatment  is 
inconvenient;  the  ward-tenders  dislike  it,  the  sisters  of  charity  oppose  it 
because  it  soils  the  bed-clothes,  and  at  the  commencement  of  salivation, 
when  it  is  indispensable  to  clean  the  skin  thoroughly  and  give  fresh  linen 
in  order  to  prevent  further  absorption,  they  neglect  these  small  atten- 
tions, and  the   severest  inflammation  of  the  gums  results.     Add  to  this, 


124  THERAPEUTICS. 

that  the  wards  are  not  tight,  that  sweeping  and  ventilation  are  performed 
morning  and  evening  without  pity  or  regard,  and  that  the  unhappy  patient 
is  exposed  to  all  the  evil  consequences  of  an  energetic  mercurial  treat- 
ment. We  therefore  abandoned  the  treatment  at  our  hospital,  not  be- 
cause it  did  not  seem  preferable  to  others  which  we  knew,  but  because 
we  could  not  secure  the  required  care  and  attention. 

Now,  however,  having  learned  the  method  of  Law,  we  no  longer  hesi- 
tate to  push  the  drug  till  the  gums  begin  to  swell  and  salivation  appears. 
The  fever  is  sensibly  diminished  by  that  time,  and  we  then  use  sulphate 
of  quinia  in  the  dose  of  1  or  2  grammes  (gr.  15 — 30)  per  diem  as  di- 
rected by  M.  Briquet,  powdered  digitalis  in  the  dose  of  from  a  quarter  of 
a  gramme  to  a  gramme,  which  mixed  method  has  seemed  to  us  the  most 
effective  in  acute  rheumatism. 

Chronic  articular  rhewnatism. — We  cannot  speak  too  highly  of  the 
happy  influence  of  mercury  in  this  complaint,  whether  it  be  the  conse- 
quence of  blennorrhagia  or  the  remains  of  an  acute  malady  caused  by 
cold.  One  of  our  pupils,  M.  Bonardel,  wrote  his  thesis  upon  this  subject 
in  1834  [Journal  des  conyiaissances  medico-cliirurgicales,  t.  II.,  p.  50), 
since  when  we  have  had  many  occasions  to  repeat  his  experiments. 

Subsequently  to  synovial  rheumatism,  which  ma}'  not  have  been  very 
marked,  we  sometimes  see  several  joints  in  succession  swell,  and  the  symp- 
toms increase  more  or  less  rapidly;  the  enlargement  is  like  that  of  the 
first  stage  of  white  swelling,  and  we  have  seen  a  young  man  almost  all  of 
whose  joints  were  affected.  The  swelling  is  situated,  not  only  in  the 
soft  parts,  but  also,  and  more  commonh',  in  the  bones  and  fibrous  tissue. 
It  is  quite  remarkable  that,  in  this  case,  fluctuation  is  rarely  observed  in 
the  synovial  capsules. 

In  this  case  we  do  not  need,  as  in  peritonitis  and  acute  synovial  rheu- 
matism, to  push  the  mercurial,  and  produce  instantly  the  state  of  cachexia 
to  which  is  very  probably  due  the  good  effect  of  mercurials  in  these  two 
inflammations.  The  chronic  state  requires  a  chronic  treatment,  if  we  may 
express  ourselves  thus  ;  let  us,  therefore,  employ  weak  and  graduated 
doses,  as  in  constitutional  syphilis.  The  best  method,  in  our  experience, 
is  that  by  baths  of  sublimate.  The  bath  for  an  adult  may  contain  from 
8  to  30  grammes  (  3  ii. —  1  i-)  of  sublimate  in  solution,  and  may  be  em- 
ployed daily  or  on  alternate  days;  we  continue  thus  till  the  swelling  and 
pain  are  entirely  gone.  This  treatment  is  accompanied,  as  in  constitu- 
tional syphilis,  by  concentrated  sudorific  drinks,  some  simple  baths  and 
vapor-baths,  and  is  terminated  by  fumigations  of  cinnabar  in  an  apparatus 
which  does  not  expose  the  head  to  the  fumes. 

The  English  prescribe  in  this  case  pills  of  calomel  and  opium  according 
to  the  following  formula  : 

Calomel 3  parts. 

Opium 1      „ 

Conserve  of  roses q.  s. 


k 


ALTERATIVES.  125 

To  be  made  into  pills  each  containing  10  centigrammes  (gr.  iss.)  of 
calomel;  one  or  two  to  be  taken  daily. 

There  is  a  form  of  chronic  rheumatism,  or  rather  atonic  gout,  observed 
more  especially  in  women,  which  attacks  the  joints  successively  and  at 
last  becomes  a  most  afflicting  complaint.  M,  Lasegue,  who  has  published 
an  excellent  paper  on  this  disease,  which  he  calls  nodose  rheumatism,  in 
the  Ai-chives  de  medecine,  finds  that  mercurials  were  almost  always  use- 
less, and  that  tincture  of  iodine  continued  for  several  months  in  the  enor- 
mous dose  of  3 — 5  grammes  (gr.  30 — 75)  per  day,  checked,  and  sometimes 
cured  this  terrible  disease.  We  have  tried  this  method  and  found  it 
beneficial. 

The  sublimate  baths  have  seemed  to  us  much  less  useful  in  interar- 
ticular  chronic  rheumatism  than  in  that  which  is  seated  in.  the  joints. 
Nevertheless,  in  our  practice,  we  have  two  or  three  times  obtained  so 
rapid  improvement  that  we  were  tempted  to  think  that  syphilis  had  some- 
thing to  do  with  the  pains. 

Pldegmasim. — We  cannot  omit  the  curious  facts  reported  by  Dr. 
Gobee,  in  regard  to  the  use  of  high  doses  of  calomel  in  pneumonia 
(Schmidt's  Journal  de  med.,  loth  vol.,  2d  part).  This  treatment  had 
been  advised  by  Hamilton  towards  the  end  of  the  last  century,  and  later 
by  Vogel.  It  is  as  follows:  blood  is  first  let,  and  soon  after,  calomel  is 
given  in  the  dose  of  from  ^  to  1^  grammes  in  the  twenty-four  hours  (gr.  8 
— 23),  in  12  doses.  He  increases  the  interval  between  the  doses  a  little  if 
no  diarrhoea  follows.  If  the  cough  is  frequent,  he  adds  extract  of  hyos- 
cyamus  to  the  calomel.  A  few  days  suffice  to  lessen  the  inflammatory  symp- 
toms, when  the  medicine  is  stopped.  M.  Gobee  has  observed  that  saliva- 
tion very  rarely  occurs  in  pneumonia  (JSidl.  de  th'erap.,  octobre,1837). 

We  have  seen  the  happy  effect  of  mercurials  upon  phlegmasife  which 
were  very  dangerous  from  their  extent,  their  seat,  or  their  febrile  reaction. 
There  is  no  reason  to  doubt  that  this  is  the  case  with  the  other  phleg- 
masiiB  also,  and  we  are  hardly  surprised  at  the  confidence  which  our 
neighbors  beyond  sea  bestow  upon  calomel  in  inflammation.  The  unani- 
mous agreement  in  regard  to  the  antiphlogistic  properties  of  mercury 
which  is  found  among  such  a  mass  of  physicians  as  those  of  England, 
British  India,  and  North  America,  compels  us  to  believe  that  there  is 
some  truth  there;  and  it  is  really  deplorable  that  our  countrymen  have 
such  prejudices  against  this  heroic  remedy. 

Diseases  of  the  liver. — The  value  of  mercury  in  these  diseases  has 
become  a  sort  of  commonplace.  A  sort  of  tacit  agreement  exists  among 
all  physicians  upon  this  point,  and  although  well-conducted  and  conclu- 
sive experiments  have  not  yet  been  published,  it  is  still  customary  for 
mercurials  to  form  a  part  of  all  treatments,  whether  empirical  or  rational, 
of  those  suffering  from  chronic  disease  of  the  liver.  It  is  difficult  for  us 
to  decide  in  this  question,  and  we  shall  refrain  from  giving  any  opinion, 
until  we  have  made  experiments  which  satisfy  us. 

We  have,  however,  recently  observed  certain  facts  which  have  im- 


126  THERAPEUTICS. 

pressed  us  very  favorably.  We  are  acquainted  with  patients  who  have 
long  suffered  with  a  gastro-hepatic  affection,  quite  hard  to  define,  but 
accompanied  with  some  congestion  of  the  liver,  and  that  painful  condi- 
tion vaguely  known  as  hepatalgia. 

Many  remedies  had  been  used  without  success  in  these  cases,  and 
they  were  at  last  cured  by  mercurials,  which  were  given  quite  empirically. 
We  can  speak  of  a  lady,  among  others,  who  had  for  years  been  tormented 
by  an  ill-determined  complaint  of  the  liver,  termed  an  anomalous  neuro- 
sis of  the  gastro-hepatic  plexuses.  This  patient  had  exhausted  every- 
thing without  relief,  when  she  met  at  the  sea-side  an  English  physician 
who  ordered  blue  pills,  which  seem  to  possess  a  most  remarkable  fund- 
ent,  laxative,  and  resolvent  power.  Under  this  treatment  the  disease, 
previously  so  painful  and  refractory,  had  in  a  short  time  completely 
changed  its  face,  and  a  cure  soon  followed,  as  happy  as  it  was  unexpected. 
These  results  agree  with  the  observations  of  Monneret,  who  has  found 
benefit  from  blue  pills  in  cirrhosis. 

The  English  use  calomel  a  great  deal  as  a  cholagogue  cathartic  in 
abdominal  plethora  and  hepatic  congestion  marked  by  colorless  stools, 
flatulent  dyspepsy,  paleness  and  sadness  of  countenance,  which  they  call 
torpor  of  the  liver,  and  treat  it  with  Plummer's  pills,  which  have  a  great 
repute  across  the  Channel.  These  pills  are  composed  of  calomel,  preci- 
pitated sulphuret  of  antimony,  resin  of  guaiac  in  powder,  and  castor-oil. 
Each  pill  weighs  :^  of  a  gramme  and  contains  -^^  of  a  gramme  (nearly^  of 
a  grain)  of  calomel.  '  They  undergo  alteration  after  a  time,  by  tlie  forma- 
tion of  sulphate  of  mercury  and  terchloride  of  antimony.  The  English 
also  claim  that  the  good  effect  of  these  pills  is  perhaps  due  to  the  anti- 
mony as  much  as  to  the  mercury  (Fonssagrives:  Bulletin  de  th'erapeu- 
tique,  t.  LXXI.      '•  Du  role  du  calomel  dans  la  medecine  anglaise  "). 

Diarrhoea. — The  English  use  calomel  in  diarrhoea  with  a  boldness  to 
which  we  are  not  used.  In  feculent  or  irritative  diarrhoea  they  give  a 
gentle  purgative  first,  and  afterwards,  if  the  stools  do  not  change,  they 
give  in  the  evening  a  large  dose  of  calomel,  and  next  morning  castor-oil. 
It  is  the  English  habit  to  give  calomel  first  and  a  light  purgative  after- 
wards, thus  avoiding  the  alterant  effect  of  mercury  while  employing  it  as 
a  purge,  a  cholagogue  and  a  deobstruent  of  the  liver.  In  mucous  or 
catarrhal  diarrhoea,  they  also  give  at  night,  calomel  with  Dover's  powder 
or  sulphate  of  potassium,  and  the  next  morning,  castor-oil;  in  serous  or 
bilious  diarrhoea  they  consider  it  as  contra-indicated. 

Dysentery. — The  incontestable  value  of  purges  in  most  epidemics  of 
dysentery,  permits  us  to  believe  in  the  good  effects  of  calomel,  given  in- 
ternally. Experience  shows  that  calomel  given  in  the  dose  of  2  grammes 
(30  gr.),  night  and  morning,  is  one  of  the  most  effective  agents  in  treat- 
ing this  dangerous  disease.  Under  this  treatment  the  bloody  and  mucous 
stools  quickly  lose  these  characters.  The  cutting  pain  and  tenesmus 
moderate,  and  the  stools  take  the  dark  green  color  which  always  follows 
the  administration  of  calomel.     The  use  of  calomel  is  not  to  be  suspended 


ALTERATIVES.  127 

until  the  stools  have  taken  this  peculiar  color.  Does  the  medicine  act 
here  as  a  substitutive,  and  consequently  by  its  local  irritant  power,  or  as 
an  alterant '?  This  is  not  easy  to  decide.  We  are  led  to  think  that  the 
alterant  action,  in  this  case,  has  a  subordinate  part,  for  we  never  heard 
that  mercurial  frictions  had  ever  been  used  to  advantage  in  treating  dys- 
enter\',  unless  perhaps  by  Boage  (Gmelin:  "  App.  med.,"  t.  VIII.,  p.  95). 
To  Dr.  Aniiel,  surgeon -major  of  the  12th  regiment  of  the  English  army, 
is  due  the  credit  of  first  clearly  formulating  this  method. 

He  made  several  successful  trials  of  it  in  an  epidemic  of  dysentery, 
which  prevailed  among  the  garrison  of  Gibraltar,  in  1812,  and  the  state- 
ment of  the  physician  in  charge  at  the  fortress  attests  the  excellence  of 
the  metliod.  May  we  suppose  that  it  would  be  equally  successful  in  all 
epidemics  of  dysentery  ?  We  doubt  it;  and  it  is  sufficient  to.  mention 
the  plan,  which  will  probably  be  useful  in  a  great  many  cases.  Dr. 
Roesch  bestows  high  praise  upon  calomel  in  large  doses  in  severe  dysen- 
tery. He  commences  with  a  few  leeches  to  tho  hypogastrium  or  anus, 
and  follows  them  up  by  calomel  in  the  dose  of  20  (gr.  iij.)  centigrammes 
for  children,  and  50  centigrammes  (gr.  viiss. )  for  adults,  in  two  doses, 
one  in  the  morning  and  one  at  night;  sometimes  also  one  in  the  mid- 
dle of  the  day.  He  associates  the  acetate  of  morphia  in  case  of  acute 
pain  and  tenesmus. — He  uses  calomel  also  in  high  doses,  in  typhoid 
fever  {Medizinische  Annalen,  1839). 

In  an  epidemic  of  dysentery  which  raged  among  the  garrison  of  Tours 
during  the  autumn  of  1850,  Dr.  Frederic  Leclerc  had-  fresh  evidence  of 
the  great  value  of  this  remedy.  He  begins  with  a  small  dose,  10  centi- 
grammes (gr.  1"5)  per  day,  in  several  doses,  and  raises  the  dose  gradu- 
ally until  it  reaches  40  and  50  centigrammes  (gr.  G — 7),  unless  there  is 
considerable  improvement  after  a  few  days  of  treatment.  At  the  same 
time  he  covers  the  belly  with  extract  of  belladonna  to  quiet  the  tenes- 
mus. 

As  regards  the  form  and  period  of  the  complaint  which  call  for  the 
use  of  calomel,  we  will  only  say  that,  in  acute  dysentery,  the  leading 
phenomena — fever,  diarrhoea,  hiemorrhage,  rectal  spasm — are  not  always 
present  in  equal  proportions.  The  malady  is  sometimes  chiefly  inflamma- 
tory and  febrile,  when  bloodletting  relieves  more  than  anything  else; 
sometimes  spasm  is  prominent,  requiring  stupefiant  injections;  again, 
haemorrhage  is  the  chief  symptom  when  purges  are  prescribed,  especially 
those  acting  on  the  upper  intestine  or  liver,  like  castor-oil  and  calomel. 
Morehead  (cited  by  M.  Fonssagrives)  prescribes  calomel  during  the  first 
two  or  three  days  in  persons  enfeebled  by  previous  disease.  He  gives  at 
night  a  powder  composed  of 

Calomel gr.  0*50     =:7*5  grains. 

Ipecac, 

Opium aa  gr.  0-025    =0-4       " 

and  next  morning,  16 — 30  grammes  (  3  ss. —  3  i.)  of  castor-oil.     We  would 


128  THERAPEUTICS. 

gladly  accept  this  plan,  but  not  the  radical  treatment  which  Annesley 
ordered  in  India,  and  which  is  now  partly  abandoned.  Finally,  acute 
dysentery  may  have  the  bilious  character,  and  be  quickly  benefited  by 
calomel,  as  M.  Pecholier  gave  it  in  an  epidemic,  in  1864,  at  the  hospital 
Saint-Eloi  at  Montpellier  ("  Des  indications  de  I'emploi  du  calomel  dans 
le  traitement  de  la  dysenterie,"  1865,  Paris).  As  for  the  adynamic  or 
putrid  form  of  dysentery,  it  contraindicates  calomel  and  is  much  better 
treated  with  cinchona.  The  same  indications  may  be  followed  in  chronic 
dysentery. 

JVetfroses. — If  we  exclude  from  the  neuroses  cured  by  mercury  those 
which  are  due  to  syphilis,  the  number  will  seem  very  small;  it  is  there- 
fore prudent  always  to  look  for  syphilis  in  the  antecedents  of  patients 
affected  with  neuroses. 

A  young  attache  of  the  English  embassy  had  had  several  venereal 
attacks,  and  thought  himself  cured,  wlien  he  began  to  suffer  from  epilep- 
tic vertigo,  and  soon  from  general  epileptic  convulsions.  Treated  by  the 
best  physicians  of  London  and  Paris,  he  thought  himself  incurable,  and 
planned  to  kill  himself.  He  consulted  Dr.  Lebreton  and  ourselves. 
Nothing  about  him  indicated  the  existence  of  syphilis,  but  he  had  several 
times  been  treated  for  that  disease  without  mercury,  and  this  led  us  to 
think  that  the  venereal  poison  might  be  a  cause  of  the  nervous  disorders 
of  late  years.  We  prescribed  a  regular  mercurial  treatment,  and  the 
disease  disappeared;  and  for  sixteen  years  the  gentleman  has  not  had  the 
slightest  suspicion  of  a  disease  which  had  rapidly  become  very  alarming. 
In  1855  we  had  another  equally  rapid  and  complete  success  in  the  case 
of  a  Spanish-American,  who,  after  a  constitutional  syphilis,  had  had  daily 
attacks  of  epilepsy.  Of  course  we  do  not  infer  that  mercury  cures  epi- 
lepsy, but  only  that  epilepsy  may  be  due  to  cranial  exostoses,  vegetations 
of  the  dura  mater,  or  any  other  appreciable  or  inappreciable  lesion  of  the 
nervous  system  due  to  the  venereal  infection;  and  that  mercury  cures 
epilepsy,  not  by  its  anti-epileptic,  but  by  its  anti-syphilitic  powers;  and 
the  same  in  certain  paralyses,  and  mania,  which  are  sometimes  due  to  the 
same  immediate  material  causes  and  the  same  remote  cause  as  the  epi- 
lepsy of  which  we  speak.  Thus  paraplegia,  hemiplegia,  amaurosis, 
deafness,  have  been  cured  by  mercury,  when  dependent  directly  or  indi- 
rectly upon  pox. 

Certain  neuralgias  are  in  the  same  category.  A  rich  banker  of  Paris, 
whose  life  had  not  been  quite  regular,  had  suffered  for  ten  years  from 
pains  in  the  stomach  and  vomiting,  which  returned  every  evening  and 
which  nothing  could  relieve.  A  mercurial  treatment  was  advised,  rather 
from  the  memory  of  old  attacks  of  syphilis  than  in  the  hope  of  cure.  As 
soon  as  salivation  began,  the  functions  of  the  stomach  were  re-established, 
and  from  that  time  the  health  was  excellent.  In  this  case  the  pains  and 
other  symptoms  were  nocturnal,  which  was  the  only  point  of  contact 
with  sj'philis  that  induced  the  prescription  of  mercury.  We  have  also 
seen  two  women,  one  at  the  Hotel-Dieu,  the  other  in  our  private  practice, 


ALTERATIVES.  129 

who  had  intolerable  neuralgic  pains  of  the  face  and  forehead  every  day 
at  a  fixed  hour,  usually  towards  noon.  Everything  proved  futile,  until 
we  gave  mercury,  when  a  cure  was  obtained  in  a  few  days.  We  had 
learned  that  these  women  had  had  syphilis,  and  had  never  taken  any 
mercurial.  We  add  that  in  1836  and  1855  we  attended  two  women  af- 
fected with  intermittent  periodic  diurnal  neuralgias,  accompanied  by 
cranial  exostoses.  Mercury  quickly  cured  them,  though  iodide  of  potas- 
sium had  failed. 

When  a  new  remedy  for  tetanus  is  mentioned,  a  feeling  of  distrust 
naturally  arises;  for  very  few  of  us  have  seen  patients  recover  from  trau- 
matic tetanus.  This,  however,  is  no  reason  for  not  making  any  trials, 
and  for  rejecting  as  apocryphal  the  cases  of  cure  quoted  by  various  au- 
thors (Gmelin:  "  App.  med.,"  t.  VIIL,  p.  94).  But  in  our  timej  Professor 
Forget  cured  a  tetanus,  not  traumatic,  but  spontaneous,  by  mercurial 
frictions  continued  for  five  days  in  the  dose  of  30  grammes  per  day.  This 
was  at  the  clinic  of  the  Faculte  de  Medecine  at  Strasburg,  and  in  the  pres- 
ence of  many  plipils.  Would  he  have  succeeded  equally  in  a  case  of 
traumatic  origin?  This  must  remain  doubtful.  Need  we  believe  what 
Rush  and  Clarkson  said  ("Ti-ansact.  of  the  College  of  Phys.  at  Philadel- 
phia," vol.  i.,  1T93)  of  the  efficacy  of  mercurial  inunction  of  the  neck  and 
jaws  in  tetanus;  what  P.  Desault  and  Darlae  said  of  the  value  of  the 
same  method  as  a  preventive  of  hydrophobia  (Desault  "  Diss,  sur  les 
maladies  veneriennes,"  Bordeaux,  1733),  and  so  many  other  authors,  whose 
names  may  be  read  in  Gmelin  ? 


Therapeutic  Action  of  Mercuriai^s  used  as  Topics.    * 

Hitherto,  we  have  seen  mercury  acting  through  absorption,  and  af- 
fecting the  parts  it  benefits  indirectly.  Now  we  have  to  study  it  as  a 
topic,  that  is,  acting  directlj^  modifying  the  tissue  with  which  it  is  in  im- 
mediate contact,  and  entering  the  system  through  the  diseased  organ. 
Of  all  the  agents  of  substitutive  medicine,  there  is  probably  none  which 
receives  more  numerous  applications  than  mercury. 

N'on-syphllitic  disease  of  the  skin. — The  value  of  mercury  in  diseases 
of  the  skin  is  as  unquestionable  as  it  is  in  syphilis.  This  precious  medi- 
cine was  introduced  as  a  remedy  for  skin  diseases,  as  the  writings  of  the 
Arabs  show;  and  it  was  simply  because  its  virtues  had  been  solemnly  rec- 
ognized in  leprosy,  that  it  was  used  in  syphilis,  the  most  hideous  of  diseases 
next  to  leprosy.  Many  charlatans,  seeing  syphilis  appear  in  the  form  of 
cutaneous  disorders,  and  thinking  that  all  diseases  of  the  skin  were  due  to 
the  same  cause,  gave  mercury  empirically,  with  a  success  which  opened 
the  eyes  of  all  physicians  who  were  not  closed  to  all  truth.  Mercurial 
ointments  have  long  been,  and  still  are  the  most  popular  secret  remedy 
for  chronic  diseases  of  the  skin. 

We  may  sav  of  sublimate,  as  a  topical  remedv,  that  it  is  supreme  in 
9' 


130  THERAPEUTICS. 

the  treatment  of  cutaneous  diseases;  and  there  is  little  exaggeration  in 
claiming  that  mercury  by  itself  suffices  in  the  treatment  of  almost  all 
these  affections.  The  Neapolitan  ointment,  red  precipitate,  calomel,  cor- 
rosive sublimate,  cinnabar,  the  iodides  of  mercury,  etc.,  are  very  powerful 
weapons  which  we  should  learn  well  to  handle.  Among  these,  the  subli- 
mate is  certainly  the  most  heroic,  and  does  more  service  than  all  the  rest 
together. 

Baume  was  the  first  to  give  it  in  baths,  for  diseases  affecting  the 
greater  part  of  the  skin.  He  was  probably  led  to  this  by  having  experi- 
mented with  lotions  of  sublimate,  and  with  certain  secret  remedies,  parti- 
cularly the  anti-dartrous  water  of  the  Cardinal  de  Luynes,  which  was 
merely  a  solution  of  sublimate.  He  had  also  seen  the  rapidity  with  which 
the  phagedsenic  water,  used  as  a  lotion,  cured  dartres,  especially  tliose 
which  are  accompanied  with  itching. 

These  baths,  prescribed  at  first  in  the  dose  of  from  4  to  8  grammes 
(  3  i- — ii.)  to  300  litres  (quarts)  of  water,  fell  into  disuse  for  diseases  of 
the  skin;  but  they  were  readopted  by  Wedekind  [Ileidelberger  kliniscJie 
Annalen,  1829,  v.,  537),  which  brought  them  back  into  credit.  They  were 
not  naturalized  in  France  until  we  had  tried  them  on  a  large  scale  at  the 
Hotel-Dieu  in  Paris  during  the  years  1831,  '32,  and  '33,  showing  to  a  dem- 
monstration  the  remarkable  efficacy  of  baths  of  sublimate  in  the  chronic 
diseases  of  the  skin,  whether  of  syphilitic  origin  or  not.  Tlie  baths  which 
we  order  in  this  case  contain  at  first  15  grammes  (225  grains),  which  is 
gradually  increased  to  30  or  GO  grammes  (about  3  i. — ii.).  The  dose  for 
women  is  always  less  by  a  half. 

Independently  of  their  curative  action,  these  baths  produce  an  effect 
on  the  skin  and  the  entire  system  which  is  important.  The  first  taken 
may  cause  heaviness  of  the  head  and  an  invincible  tendency  to  sleep, 
sometimes  light  spasms  of  the  stomach  and  very  slight  colics,  rarely  fol- 
lowed by  vomiting  or  diarrhoea.  These  phenomena  cease  after  the  first 
baths,  and  a  second  set  appear,  ordinarily  a  papular  eruption  on  the  legs, 
which  is  quite  like  lichen  agrius,  and  produces  severe  itching  or  smarting. 
This  eruption  is  not  dissipated  by  successive  baths,  but  increases,  and 
often  forces  us  to  give  up  the  baths. 

We  never  give  the  baths  so  as  to  produce  salivation,  unless  it  be  for 
the  relief  of  syphilitic  symptoms.  We  order  them  to  be  taken  every 
other  day,  and  usually  a  bath  of  bran-water  on  the  intervening  days. 

Great  care  should  be  taken  never  to  give  to  a  patient  sulphur-baths 
and  sublimate-baths  at  once,  nor  to  order  mercurial  baths  directly  after 
those  of  sulphur,  as  the  skin  becomes  of  a  brown-black,  which  persists  un- 
til the  entire  epidermis  has  fallen. 

In  default  of  baths,  lotions  of  sublimate  are  used  for  the  same  purpose. 
The  formula  most  used  by  us  is  the  following  : 

Corrosive  sublimate 10  grammes  =  gr,  150 

Alcohol    100        "  =3  XXV. 


ALTERATIVES.  131 

Of  this  solution,  a  teaspoonful  in  500  grammes  (1  pint)  of  very  hot 
water  for  lotions.  The  proportion  of  the  solution  may  be  increased  or 
diminished  according  to  circumstances. 

The  anti-dartrous  water  of  the  Cardinal  De  Luynes  formerly  enjoyed  a 
great  reputation  for  the  cure  of  skin  diseases.  In  England,  the  perfumers 
sell  a  wash  celebrated  among  women  for  curing  acne  rosacea  and  the 
diseases  of  the  skin  of  the  face  ;  it  is  composed  as  follows: 

Liquor  Gowlandii  (Codex) — Gowlanb's  Wash. 

Bichloride  of  mercury 1  part. 

Muriate  of  ammonium 6     " 

Emulsion  of  bitter  almonds 480 

Pityriasis  capitis. — There  is  a  form  of  pityriasis  of  the  scalp  which  is 
very  common  in  young  girls  from  fifteen  to  twenty  years  old,  at  the  period 
when  the  hair  develops;  this  is  promptly  cured  by  the  following  pomade: 

Beef  marrow 20  grammes=gr.  310 

Lard 4       "  ="      63 

Tincture  of  cantharides 0.60  =  "        9\ 

Calomel ' 0.25  ="        3f 


Essence  of  bitter  almonds 2  droj: 


3S. 


Malignant  pustule  ;  cauterization  icith  sublimate. — In  an  extended 
paper  on  this  disease,  addressed  to  the  Medical  Association  of  Eure-et- 
Loir,  by  Dr.  Salmon  of  Chartres,  the  author,  after  explaining  the  use 
made  of  different  caustics,  as  the  actual  cautery,  nitrate  of  silver,  potassa, 
etc.,  recommends  especially  the  sublimate,  which  the  physicians  of  Beauce, 
where  charbon  is  so  common,  make  very  great  use  of.  In  our  country, 
says  he,  corrosive  sublimate  enjoys  the  most  extensive  reputation;  it  has 
become  the  usual  remedy  in  malignant  pustule,  owing  to  the  communica- 
tions made  by  MM.  Poulain,  Vaucoret  and  Harreaux,  who  have  made  ex- 
periments with  it.  The  curers  themselves,  those  who  refuse  to  give  the 
public  what  they  call  their  secret,  are  driven  to  color  their  drug  red, 
green,  or  otherwise,  in  order  not  to  seem  to  do  as  every  one  else  does. 
Their  secret  is,  nevei'theless,  nothing  but  bichloride  of  mercury. 

Although  the  remedy  is  so  generally  used  in  the  country,  the  methods 
used  by  physicians  differ, 

M.  Montagnier,  who  practised  at  Gallardon  twelve  years  ago,  and  had 
a  wide  local  reputation  for  curing  charbon,  operated  as  follows: 

He  made  little  diachylon  plasters  about  as  large  as  a  two-franc  piece, 
incorporating  a  large  quantity  of  sublimate  with  the  diachylon,  and  sprink- 
ling its  softened  surface  with  lumps  of  sublimate  just  before  applying  to 
the  skin.  This  first  plaster  was  kept  on  the  skin  six  hours,  after  which 
a  second,  more  heavily  charged,  was  applied,  and  left  on  for  twelve  hours. 
When   rapid  action  was  necessary,  he  scarified  with  the  lancet  the   first 


132  THEKA  PEUTICS. 

eschar  obtained.  In  all  cases,  after  the  second  plaster  he  made  a  circular 
incision  in  the  tumor  with  the  bistoury.  He  afterwards  dressed  with 
styrax,  pure  or  mixed  with  sublimate,  in  small  proportions. 

M.  Vaucoret,  a  physician  at  Denouville,  whose  father  also  enjoyed  at 
Beauce  a  deserved  reputation  for  his  success  in  treating  charbon,  operates 
more  simply.  When  the  patient  presents  himself,  he  first  makes  a  crucial 
incision  in  the  tumor  with  the  lancet,  down  to  the  healthy,  that  is,  the 
sensitive  parts,  which  should  not  much  exceed  a  centimetre  (3%  inch)  for 
each  side;  then  with  a  bistour}'  or  curved  scissors  he  removes  the  four 
lappets  produced  by  the  incision,  A  cup  results,  the  bottom  of  which  is 
at  the  central  point  of  the  pustule,  and  the  edges  answer  to  the  sound  tis- 
sues. A  good  deal  of  blood  usually  escapes,  which  is  stanched  with 
charpie  or  cotton  before  the  pounded  sublimate  is  applied;  the  cup  is 
filled  with  the  powder,  and  a  plaster  is  put  on  over  all.  The  amount  of 
sublimate  used  may  be  one  or  two  grammes  (gr.  15 — 30). 

Twenty-four  hours  later,  if  the  patient  has  suffered  much  (which  shows 
that  the  caustic  has  reached  tlie  sound  parts),  if  a  proper  eschar  has 
been  formed,  if  around  the  eschar  there  is  a  circle  of  vesicles  containing 
a  sero-purulent  liquid,  showing  a  return  to  the  normal  function  of  the 
diseased  parts,  the  accidents  produced  by  the  malignant  pustule  are 
checked;  but  if  the  patient  has  suffered  little  or  not  at  all,  if  the  circle 
of  blisters  has  not  been  formed,  it  is  important  to  recommence  the  above 
cauterization. 

Dr.  Missa  states  that  during  ten  years  he  has  used  no  other  remedy, 
and  that  in  more  than  300  cases  he  has  failed  but  twice.  In  one,  the  pa- 
tient did  not  appear  till  the  seventh  day  of  the  disease,  and  in  the  other, 
the  patient  was  already  infected  ("  Union  med.,"  1863). 

Phageda?nic  water  may  replace  sublimate  with  advantage  whenever  the 
action  of  the  mercury  must  be  exclusively  topical.  It  is  mixed  with  hot 
water  in  the  proportion  of  one-sixth,  a  quarter,  a  half,  and,  with  the  mix- 
ture, repeated  and  quite  prolonged  lotions  are  made.  Before  using  the 
water,  the  bottle  must  always  be  well  shaken. 

Cinnabar,  being  insoluble,  is  not  so  convenient  to  use;  yet  it  is  em- 
ployed in  analogous  circumstances. 

The  topical  uses  of  cinnabar  were  formerly  little  known,  Gmelin,  in 
his  "  Apparatus,"  cites  but  few  authors  who  thus  used  it.  It  was  used  for 
the  itch,  tinea,  and  other  chronic  affections  of  the  skin  ("  App.  med.," 
t,  II.,  p.  129).  At  present  it  is  used  only  in  fumigations.  It  is  volatilized 
on  a  plate  of  platinum  or  porcelain,  and  the  vapor  is  directed  to  the  parts 
to  be  cured.  A  fumigating-box  is  commonly  used,  with  holes  to  introduce 
a  limb,  or  to  which  a  surface  of  the  body  is  applied.  When  it  is  thought 
fit,  for  a  general  cutaneous  disease,  to  give  general  fumigations,  the  per- 
son is  put  in  a  box,  his  head  alone  being  outside.  This  apparatus  was  in- 
vented by  Lallouette,  at  the  end  of  the  last  century,  and  is  daily  modified 
to  suit  the  idea  of  the  physician  and  the  special  indications. 

Fumigation  with  cinnabar  as  a  local  remedy  is  particularly  useful  in 


ALTERATIVES.  133 

cutaneous  syphilidji?;  it  is  also  of  great  use  in  phthiriasis,  a  multiple  erup- 
lion,  caused  by  the  presence  of  lice.  The  doses  of  cinnabar  vary  from  50 
centigr.  to  8  and  12  grammes  (gr.  8  to  3  ii- — iii.),  according  to  the  extent 
of  surface  to  be  treated,  the  capacity  of  the  apparatus  used,  and  the  sen- 
sibility of  the  parts. 

Acute  suppurative  jMegmasloi. — The  acute,  as  well  as  the  chronic  dis- 
eases of  the  skin,  have  been  topically  treated  by  mercurials. 

Phlegmonous  erysipelas  of  the  limbs  and  panaris  have  been  advantage- 
ously treated  with  high  doses  of  mercury,  in  topical  applications,  or  given 
internally  so  as  quickly  to  affect  the  system. 

M.  Serres,  of  Alais,  is  the  chief  advocate  of  the  local  use  of  mercurial 
friction  in  erysipelatous  and  erysipelato-phlegmonous  inflammations.  The 
extent  of  his  applications  depends  on  that  of  the  disease;  he  does  not  hesi- 
tate to  use  250 — 300  grammes  (  3  viii. — ix.)  of  double  Neapolitan  ointment 
in  the  space  of  48  hours.  After  this  period  the  inflammation  usually  re- 
cedes, when  the  remedy  should  be  suspended;  but,  if  this  favorable  turn 
does  not  occur,  the  treatment  must  be  persisted  in  without  fear  of  saliva- 
tion, which  does  not  usually  occur  until  the  fourth  or  fifth  day  (  Gaz.  med., 
1837,  No.  33;  Bull,  de  therap.,  1833,  t.  IV.;  1837,  t.  XII.). 

M.  Serres  has  used  the  same  treatment  in  panaris.  By  rubbing  upon 
the  finger,  before  the  suppuration  commences,  double  mercurial  ointment 
every  quarter  of  an  hour,  or,  more  simply,  by  enveloping  the  finger  in  a 
mass  of  Neopolitan  ointment,  he  causes  very  threatening  panaris  to  abort 
{Bull,  de  therap.,  1833,  t.  VI.).  Traumatic  phlebitis,  due  to  venesection, 
is  cured  by  analogous  methods  (Picai-d:  Bull,  de  therap.,  t.  XIV.,  1838). 
Even  an  acute  eczema  caused  by  local  application  of  a  mercurial  ointment 
is  very  easily  cured  by  washes  of  sublimate. 

Variola. — Mercurial  inunctions  have  been  recommended  in  small-pox. 
The  face  is  covered  with  Neapolitan  ointment,  and  it  is  claimed  that  by 
this  means  erysipelatous  tumefaction  of  the  skin  of  the  face  and  eyelids 
is  avoided.  The  physician  of  the  hospital  of  Trompeloup  is  an  authority 
for  stating  that  this  is  the  most  efficient  remedy  for  preventing  the  swell- 
ing of  the  lids.  M.  Goblin,  of  Stains,  claims  to  be  able  to  make  the  pus- 
tules abort,  by  making  frequent  frictions  with  mercurial  ointment  upon 
the  affected  parts  from  the  commencement  of  the  disease.  We  shall  not 
go  so  far  as  he  does,  but  we  can  affirm  that  the  application,  made  at  the 
beginning  of  the  disease,  singularly  lessens  the  eruption  and  the  consecu- 
tive cicatrices. 

The  internal  use  of  mercurials  in  variol^e  has  received  a  much  more  sol- 
emn sanction.  There  are  numerous  attestations  of  its  value;  Huxham, 
Boerhaave,  Van  Swieten,  Cotugno,  are  agreed  that  it  is  useful,  either 
through  its  antiphlogistic  action,  as  in  peritonitis  and  rheumatism,  or  by 
attenuating  the  variolous  virus,  or  by  favoring  the  salivation  which,  as  we 
know,  is  so  useful  in  confluent  variola?  (Gmelin:  "  Appar,  med.,"  t.  VIII., 
p.  63). 

As  we  have  mentioned  the  local  and  general  action  of  mercurials  in 


134:  THERAPEUTICS. 

variolje,  we  must  mention  the  statements  made  regarding  the  action  of 
emplastrum  de  Vigo  cum  mercurio  upon  pustules  with  which  it  comes  in 
contact. 

The  honor  of  this  discovery  is  disputed  by  several  physicians,  but  it 
is  due  to  Zimmermann  and  Rosen.  We  read  in  the  Ti'ctite  de  Vexphri' 
ence,  translated  by  Lefevre  (t.  II.,  p.  206): 

"  A  lady,  who  for  good  reasons  had  placed  an  emplastrum  de  Vigo 
upon  a  certain  part,  was  salivated,  and  afterwards  had  the  small-pox, 
when  her  whole  body,  except  the  part  which  was  defended  by  the  mer- 
cury left  by  the  plaster,  was  covered  with  pustules.  M.  Malonin  has 
asked  whether  the  small-pox  might  not  be  prevented  by  this  means. 
This  experiment  has  not  been  made;  but  a  means  for  preserving  the  faces 
of  women  who  have  the  small-pox  has  been  derived  from  it.  M.  Rosen 
covered  the  face  of  one  of  his  female  patients  with  a  mercurial  plaster, 
and  the  disease  left  marks  everywhere  except  on  the  face." 

iJiseases  of  the  mucous  membranes  mid  the  eyes. — While  the  utility 
of  the  mercurials  is  so  incontestable  in  chronic  diseases  of  the  skin,  it  is 
equally  positive  in  chronic  phlegmasia?  of  the  mucous  membrane.  The 
deutoxide  of  mercury  forms  a  part  of  almost  all  the  anti-ophthalmic 
pomades,  which  were  at  first  the  secret  of  charlatans,  and  now  are  used 
daily  by  the  most  enlightened  physicians;  thus,  the  pomades  of  Desault, 
Regent,  Richter,  Dupuytren,  Lyon,  etc.,  owe  their  curative  virtues  to  red 
precipitate.  The  sublimate,  cinnabar,  the  iodides,  may  be  mingled  with 
fat  and  used  in  the  same  circumstances.  These  fatty  collyria  are  spe- 
cially of  use  in  affections  of  the  lids;  when  the  conjunctiva  is  more  partic- 
ularly affected,  dry  collyria  with  powdered  sugar  and  calomel,  or  red 
precipitate;  and  liquid  collyria  with  a  solution  of  sublimate,  occupy  an 
important  place  in  the  therapeutic  arsenal  of  ophthalmology. 

For  some  years  the  red  oxide  has  been  replaced  by  yellow  precipi- 
tate, or  hydrated  binoxide  of  mercury,  obtained  by  precipitation,  by 
treating  a  solution  of  bichloride  of  mercury  with  potassa.  Pagenstecher 
of  Wiesbaden  and  Von  Graefe  of  Berlin  have  used  it  in  preference  to  red 
oxide,  because  it  occurs  in  very  fine  powder.  The  most  usual  pomades 
are  made  as  follows: 

Hydrated  binoxide  of  mercury  (yellow  precipitate) .   1  part. 
Cold-cream  without    volatile  oil,   or    glycerolate  of 

starch 8  parts. 

This  is  most  used  in  lymphatic  and  scrofulous  ophthalmia. 
M.  Jacquet  of  May  incloses  a  similar  pomade  in  little  tin  tubes  to  keep 
it  from  turning  rancid.     His  formula  is: 

Hydrated  binoxide  of  mercury 1 

Lard 15 

Oil  of  sweet  almonds 5 

— (Societe  de  therapeutique,  1872). 


ALTERATIVES.  lo5 

Diseases  of  the  nasal  fossa?.  — Ozasna,  due  to  syphilitic  ulceration  or 
simple  chronic  inflammation  of  the  pituitary  membrane,  is  beneficially 
modified  by  frequent  inspiration  of  mercurial  powders  in  the  proportion 
of  1  or  2  grammes  of  calomel  to  15  grammes  of  sugar,  or  I — 1  gramme 
of  red  precipitate  to  15  grammes  of  sugar.  The  injection  of  sublimate 
acts  similarly. 

It  is,  however,  proper  to  assist  this  ti-eatment  by  close  attention  to 
cleanliness,  especially  by  the  injection  of  a  weak  solution  of  nitrate  of 
silver  or  sulphate  of  copper  into  the  nasal  fossie;  of  the  strength  of  5 — 50 
parts  to  10,000  of  distilled  water. 

Diseases  of  the  ear. — Mercury  renders  the  same  services  in  otorrhoea, 
in  dartrous  phlegmasite  of  the  external  auditory  meatus. 

Diseases  of  the  larynx. — We  often  make  use  of  a  powder  of  sugar- 
candy  ground  fine,  with  a  loth'or  20th  of  its  weight  of  calomel,  in  order 
to  modify  a  chronic  inflammation  of  the  laryngeal  mucous  membrane. 

Pruritus  vulval. — The  injections  and  washes  of  sublimate  or  phage- 
daenic  water  have  a  most  remarkable  efficacy  in  this  complaint,  which  is 
so  closely  related  to  dartres,  and  which  torments  the  life  of  so  many  wo- 
men.    "We  prescribe  as  follows: 

Ten  grammes  of  bichloride  of  mercury  are  dissolved  in  100  grammes 
of  alcohol.  A  teaspoonful  of  this  solution  is  put  into  half  a  litre  (a  pint) 
of  very  hot  water;  and  this  is  used  for  injections  and  washes.  We  often 
insist  on  the  necessity  of  having  the  water  very  hot,  and  not  without 
reason.  It  is  remarkable  that  lotions  of  sublimate  act  much  less  vigor- 
ously when  the  water  is  cold  than  when  it  is  very  hot,  and  the  treatment 
is  often  quite  ineffectual  because  cold  water  is  used.  Phagedagnic  water 
is  prescribed  in  the  same  circumstances,  in  the  proportion  of  a  quarter 
and  even  a  half. 

Parasitic  a^iiinals,  intestinal  ^corms. — The  action  of  mercury  upon 
the  economy  is  evidently  of  a  toxic  nature.  Its  effects  are  still  more  sen- 
sible upon  the  lower  animals,  especially  those  living  in  the  interior  of  man, 
or  on  the  skin  or  in  the  hair.  Curious  experiments  made  by  Gaspard, 
recorded  in  Magendie's  Journal  de  i:>hysiologiG  experimentale  (t.  I.,  p. 
105)  prove  this  conclusively. 

"  Several  eggs  were  placed  in  incubation  in  vases,  at  the  bottom  of 
which  was  mercury,  so  placed  as  not  to  touch  the  %^^,  but  only  to  reach 
it  with  its  exhalations.  During  six  weeks,  the  foetuses  of  ten  eggs  had 
developed  for  two  days  or  a  little  longer;  they  were  all  found  to  have 
died  at  that  period,  at  the  moment  of  the  formation  of  the  blood,  which 
could  in  some  cases  be  seen.  Two  healthy  hens  (the  q^^  being  in  the 
sixth  day  of  incubation)  exposed  only  to  the  emanations  of  mercury, 
without  direct  contact,  died  in  twenty-four  hours. 

"  In  June,  1875,  a  piece  of  meat  covered  with  eggs  of  blow-flies,  was 
placed  over  mercury  under  favorable  conditions  of  moisture  and  tempera- 
ture; not  a  single  fly  was  hatched,  while  hundreds  were  developed  in 
corresponding  experiments  made  without  mercury. 


136  '     THERAPEUTICS. 

"  -Eggs  of  the  cliimney-cricketj  some  new-laid,  some  more  advanced, 
and  some  containing  formed  fcetuses,  with  distinct  eyes  and  hmbs,  were 
placed  in  direct  and  indirect  contact  with  mercury,  and  not  one  hatched 
out;  while  all  in  a  corresponding  experiment,  made  without  mercury, 
produced  little  crickets  at  the  full  term.  The  first  being  opened,  the 
fcetuses  were  found  dead,  and  the  liquids  decomposed." 

M.  Bouchardat  has  laid  before  the  Institute  the  result  of  experiments 
made  by  him  concerning  the  effects  of  various  poisons.  He  proves  that 
the  soluble  preparations  of  mercury  are  general  poisons;  no  plant,  or  ani- 
mal, in  his  experiments,  resisted  their  influence.  Solutions  of  a  thou- 
sandth part  of  bichloride  of  mercury  rapidly  jDoison  plants.  Leeches  and 
fishes  plunged  in  the  same  solution  are  affected  instantly,  and  die  in  a 
few  minutes. 

Of  all  the  mercurials,  the  biniodide  saemed  the  most  deleterious.  A 
milligramme  of  this  salt  was  dissolved  in  1,000  grammes  of  water  (1  part 
to  one  million),  by  the  aid  of  a  milligramme  of  iodide  of  potassium;  four 
small  fishes  were  introduced,  a  cyprinus  lobula,  a  cyprinus  gobio,  and  two 
cyprini  amari.  The  two  first  died  in  three  quarters  of  an  hour;  the  others 
lived  a  few  hours.  If  the  action  of  arsenical  compounds  be  compared 
with  that  of  mercurials,  we  find  that  a  fish  lived  six  days  in  water  con- 
taining 1  gramme  of  arseniate  of  sodium  to  the  liti'e  (1  part  to  1,000; 
whence  we  may  conclude  that  the  biniodide  of  mercury  is  at  least  a  thou- 
sand times  as  poisonous  to  the  lower  animals  as  arseniate  of  soda.  M, 
Bouchardat  states  that  biniodide  is  the  most  injurious  of  the  mercurials; 
next  comes  the  bichloride,  and  next  the  cyanide. 

To  these  facts  we  will  add  others  which  prove  still  more  clearly,  if 
possible,  the  deadly  effect  of  mercury  on  insects,  and  especially  on  the 
parasites  of  man.  They  are  stated  upon  the  responsibility  of  M.  Fayard, 
a  pharmacist  of  Paris,  who  communicated  them  to  us. 

A  seedsman  of  Paris,  one  morning,  found  his  shop  and  all  his  wares 
infested  with  innumerable  quantities  of  lice.  The  poor  man,  who  could 
not  account  for  such  an  occurrence,  and  thought  an  enchantment  had 
been  cast  upon  him,  went  piously  to  the  cure  of  Saint-Vincent  de  Paul, 
to  beg  for  his  intercession  and  advice.  The  pastor  was  a  man  of  much 
intelligence,  and  was  incredulous  of  enchantment;  he  told  the  good  fel- 
low to  go  to  a  neighboring  apothecary,  who  could  give  him  some  drug 
more  powerful  than  holy  water.  This  druggist  was  M.  Fayard.  He 
went  to  the  shop,  but  dared  not  enter,  such  was  the  number  of  lice  on 
the  floor.  He  could  not  explain  this  incredible  multiplication  of  insects, 
but  planned  a  means  for  destroying  them.  A  lighted  chafing-dish  was 
set  in  the  midst  of  the  floor,  and  on  this  a  capsule  of  porcelain  contain- 
ing a  pound  of  crude  mercury;  the  doors  were  then  closed,  and  at  the 
end  of  twenty-four  hours,  when  they  were  opened,  all  the  lice  were  dead. 
The  source  of  this  singular  misfortune  was  then  sought. 

At  the  end  of  the  shop  a  bag  was  found,  almost  filled  with  dead  lice. 
It   appears  that  a  few  had  been  left  in  the  bag  of   bran  at  the  miller's; 


ALTERATIVES.  137 

they  had  quickly  multiplied  in  the  bran,  until  they  liad  eaten  it  all,  when 
they  escaped  by  a  hole  and  deluged  the  shop.  It  is  well  known  that 
the  bedbugs  in  a  room  may  be  destroyed  by  volatilizing  50  or  60  grammes 
(  3  xii. — XV.)  of  cinnabar,  and  keeping  the  room  well  closed  for  two  hours. 
Thorough  ventilation  must  be  subsequently  made,  and  the  room  left  un- 
inhabited for  a  day  or  two. 

Mercury  was  first  used  in  medicine  to  destroy  pai'asitic  animals,  as 
the  writings  of  the  Arabs  show.  Experience  confirms  this;  ointments 
containing  mercury  destroy  at  the  same  time  head-lice,  body-lice,  and 
crab-lice.  But  for  those  of  the  head  we  prefer  in  general  jDomades  made 
of  purified  lard,  slightly  perfumed,  with  a  small  proportion  (one  twenty- 
fourth)  of  red  precipitate.  For  the  other  two  kinds  we  orde.r  a  general 
bath,  in  which  we  place  80  grammes  (nearly  3  i.)  of  sublimate  previously 
dissolved  in  alcohol. 

Upon  equally  just  grounds  mercury  is  used  as  an  anthelmintic.  It 
kills  the  worms  by  its  toxic  properties,  and  expels  them  by  purging. 
Although  this  remedy  is  evidently  one  of  the  best  for  destroying  lum- 
brici,  it  is  by  no  means  equally  effective  against  teenia.  Gallaudet  also 
praised  mercurial  frictions  as  the  most  effective  means  of  destroying  the 
guinea-worm  {Journ.  de  med.  chir.  et phar.,  t.  XII.,  17G0). 

Oxyuris  vernilctdaris. — Calomel  is  more  certain  in  its  action  upon 
these  parasites  than  upon  lumbrici  or  ta^ni;^. 

For  adults  we  prescribe  an  injection  of  a  pint  of  fluid  containing 
5  centigrammes  (gr.  0'8)  of  biniodide  of  mercury  dissolved  by  the  aid  of 
y^y-  of  iodide  of  potassium,  or  the  same  dose  of  bichloride  of  mercury. 
Children  require  only  one  fourth  or  fifth  as  much.  We  have  rarely  seen 
this  treatment  fail.  Such  an  injection  may  be  taken  two  or  three  days 
in  succession;  a  fortnight  later  one  or  two  more  may  be  taken,  and  the 
same  again  after  four  or  five  weeks. 


lODINB. 

Goitre. — Coindet  made  his  first  use  of  iodine  in  goitre;  at  the  begin- 
ning of  his  practice  he  cured,  says  Coster  (Arch.  gmer.  de  med.^  t.  II., 
p.  431),  nearly  two-thirds  of  100  patients  reported  by  Coster.  Brera 
("  Saggio  clinico  sull'  lodo,"  Padua,  1822),  published  results  confirmatory 
of  Coindet's,  though  less  brilliant  than  those  reported  by  Coster.  Jansoii 
of  Lyons  {Arch.  gen.  de  med.,  t,  IV.,  p.  77),  x\ngelot  {I hid.,  t.  XII.,  p. 
135),  and  many  others,  whose  names  and  works  are  given  in  Bayle's 
excellent  compilation  ("  Biblioth.  therap.,"  t.  I.),  all  bore  witness  to  the 
same  effects.  But  in  London,  Paris,  and  some  of  the  large  German 
cities,  the  results  were  by  no  means  as  good  as  in  Switzerland  and  Italy. 
This  is  due  to  some  circumstances  which  it  is  very  important  to  mention 
here.  There  is  a  great  difference  between  the  goitre  of  the  Alps,  and 
that  which  originates  at  Paris,  for  example;  this  is  shown  by  the  nature 


138  THEEAPEUTICS. 

of  the  anatomical  lesions  seen  at  the  autopsy.  Leveille,  Eymer}',  Fodere, 
Itard,  have  shown  that  goitre  contracted  in  mountainous  countries  often 
gets  well  when  the  patient  merely  returns  to  a  country  where  it  is  not 
endemic  (Arch,  gener.  de  ined.,  t.  XXIL,  p.  135);  and  Itard  saw  at 
Lausanne  a  boarding-school  for  English  boys,  where  almost  all  the  pupils 
were  affected  with  goitre,  but  were  receiving  no  treatment,  because 
it  was  known  that  the  disease  would  leave  them  when  they  returned 
home.  This  goitre  is  only  a  hypertrophy  of  the  thyroid  gland,  and  there- 
fore is  easily  cured.  There  is,  then,  nothing  extraordinary  in  the  results 
of  Coindet,  Costa,  Brera,  and  Angelot,  whose  observations  were  made  in 
countries  where  the  disease  is  epidemic.  Those  seen  at  Paris  and  else- 
where are  not  usually  simple  develoiDments  of  the  thyroid,  but  schirrous, 
encephaloid,  tuberculous,  osseous,  cretaceous,  cartilaginous,  cystic  de- 
generations. Need  we  be  surprised  that  iodine  does  not  succeed  so  well, 
and  sometimes  even  gives  rise  to  local  accidents  b}'-  hastening  purulent 
formation  in  these  products  ?  In  therapeutics,  charges  of  ill-faith  are 
very  often  exchanged  when  the  remedies  have  simply  not  been  applied  to 
the  same  diseases. 

There  has  been  much  discussion,  and  yet  nothing  is  positively'  known 
about  the  cause  of  goitre.  Some  ascribe  it  to  meteorological  or  orographic 
conditions,  others  to  the  use  of  snow-water,  etc.  M.  Grange,  of  Geneva, 
has  lately  published  interesting  papers  on  the  cause  of  cretinism  and 
goitre,  and  tlie  means  of  preserving  the  population  from  them,  in  which 
he  tries  to  show  that  they  are  due  to  magnesian  soils,  and  water  rich  in 
magnesian  salts.  In  his  map  of  the  distribution  of  goitre  and  cretinism, 
in  France,  we  find,  contrary  to  the  usual  belief,  that  goitre  occurs  in  the 
level  lands;  it  is  endemic  in  the  Oise,  the  Aisne,  the  Somme,  the  Nord, 
and  in  the  regions  where  the  mountains  are  of  moderate  height — the 
Vosges,  the  Lyonnais,  the  Jura,  the  Drome,  etc. 

The  author  has  shown  that  no  relation  exists  between  scrofula  and 
goitre.  In  fact,  the  countries  where  goitre  is  the  worst  are  those  where 
the  scrofulous  vice  is  least  general;  as  in  the  Pyrenees  (Academie  des 
sciences,  seance  du  29  avril,  1850). 

We  think  that  before  M.  Grange's  opinion  is  received,  numerous  analy- 
ses of  the  bones  and  the  tumors  of  goitrous  persons  should  be  made. 

The  first  researches  of  M.  Chatin  showed  that  iodine  exists  not  only 
in  sea-water,  but  in  fresh  water  as  well.  Nevertheless,  water  at  its 
source  is  usually  destitute  of  it,  and  rivers  acquire  it  by  traversing  land 
which  contains  it,  and  by  receiving  the  organic  debris  of  plants  and  ani- 
mals. He  shows  that  iodine  is  a  necessary  element  of  man's  body,  fur- 
nished by  the  water  of  the  rivers  and  wells  he  drinks  from.  If  man 
drinks  in  the  mountains  water  furnished  by  melting  snow,  which  has  not 
had  time  to  become  charged  with  iodine,  he  is  in  an  abnormal  state,  from 
which  several  maladies  result,  and  particularly  goitre. 

Pursuing  these  beautiful  researches,  M.  Chatin  has  proved  the  exist- 
ence of  a  certain  proportion  of  iodine  in  the  atmosphere.     This  is  fixed 


ALTERATIVES.  139 

in  the  animal  body  by  the  act  of  respiration.  Analysis  shows  that  the 
expired  air  contains  only  about  one-fifth  as  much  as  inspired  air. 

The  air  of  badly-ventilated  and  crowded  places  is  partly  deprived  of 
iodine. 

Rain-water  is  much  richer  in  iodine  than  other  sweet  water.  The  pro- 
portion of  iodine  in  rain-water  approximately  shows  the  proportion  in  the 
air  in  a  given  country,  and  may  furnish  a  means  of  analysis. 

Snow  and  dew  are  ioduretted,  but  less  so  than  rain. 

The  chief  source  of  the  iodine  in  the  air  is  the  water,  which  continu- 
ally tends  to  give  off  the  whole  (in  fresh  water)  or  a  part  (sea-water)  of 
its  iodine. 

In  order  to  draw  some  practical  conclusions,  M.  Chatin  has  divided 
France  into  zones,  according  to  the  degree  of  iodization,.  and  he  shows 
how  to  re-establish  the  equilibrium  between  them,  by  transferring  the 
resources  of  one  zone  to  another.  He  recommends,  for  instance,  iodifi- 
cation  of  the  soil  by  manures,  by  irrigations,  by  using  the  mineral  springs 
containing  iodine,  and  by  iodizing  the  food  of  animals  which  are  eaten 
by  man. 

M.  Chatin  has  also  found  that  fermented  liquors,  wine,  cider,  perry, 
etc.,  are  richer  in  iodine  than  ordinary  fresh  water  is;  that  milk,  especially 
that  of  the  ass,  is  very  rich  in  iodine,  and  eggs  have  so  large  a  propor- 
tion that  one  egg,  weighing  50  grammes,  contains  more  than  a  quart  of 
cow's  milk,  and  as  much  as  two  quarts  of  wine  or  good  water. 

Iodine  has  been  found  in  large  quantity  in  fresh-water  animals,  espe- 
cially crayfish,  frogs,  gudgeons;  also  in  fresh-water  plants,  cress,  phillan- 
drium,  anagallis,  especially  when  growing  in  brooks.  In  general,  plants 
growing  in  running  water  are  richer  in  iodine  than  those  growing  in  stag- 
nant water. 

Most  substances,  whether  from  the  animal  or  the  vegetable  kingdom, 
which  are  offered  to  us  as  pectorals,  anti-scrofulous  and  anti-scorbutic 
remedies  par  excellence,  are  rich  in  iodine.  As  in  many  other  cases,  so 
here,  observation  did  not  wait  for  chemical  analysis  before  recognizing 
the  virtues  of  these  popular  remedies;  yet  we  are  fortunate  in  seeing  that 
science  sanctions  them,  and  converts  an  empirical  into  a  rational  reputa- 
tion. 

In  conclusion  we  would  say,  that  M.  Chatin,  thanks  to  his  elegant 
researches,  has  reached  another  and  a  most  important  conclusion,  namely: 
that  two  of  the  greatest  of  human  infirmities,  one  of  the  body  (goitre), 
and  the  other  of  the  mind  (cretinism),  are  chiefl}'  caused  by  absence  or 
deficiency  of  iodine  in  the  air  and  water,  and  that,  consequently,  the  rem- 
edy for  this  double  scourge  consists  in  restoring  to  the  system  this  prin- 
ciple, -which  is  indispensable  to  it,  as  iron  is;  and  that  the  best  method 
consists  of  a  regimen  in  which  iodized  drinks  and  food  occupy  a  leading 
place. 

The  internal  administration  of  iodine  is  not  our  only  resource;  it  has 
been  thrown  directly  into  the  tumor. 


1-iO     ,  THERAPEUTICS. 

The  iodized  injections  were  first  used  in  cystic  goitre  (Maunoir,  of  Ge- 
neva, Velpeau,  Boinet,  etc.),  and  with  very  good  results.  In  a  recent 
statement  by  M.  Patritti  ("These  de  Paris,"  1872),  we  find  that  among 
35  cases  of  cystic  goitre  thus  treated,  M.  Fleury,  surgeon  of  the  Hotel- 
Dieu  of  Clermont-Ferrand,  has  obtained  12  cures,  without  accident,  18 
cures  after  inflammatory  symptoms  of  various  degrees  of  severity,  and 
only  5  failures. 

The  method  has  lately  been  extended.  Professor  Luton,  of  Rheims, 
has  obtained  very  remarkable  results  in  four  cases  of  goitre,  by  injecting 
thirty  drops  of  tincture  of  iodine  into  the  parenchyma  of  the  tumor. 
Very  slight  inflammatory  symptoms  were  produced,  and  the  patients  re- 
covered (^Archives  de  medeclne,  octobre,  1867). 

Since  then  !M.  Luton  has  greatly  extended  his  practice,  and  always 
with  the  same  success.  He  has  been  followed  by  several  physicians,  in- 
cluding M^I.  Bertin,  de  Gray,  and  Leveque.  In  the  thesis  of  the  last 
named  we  find  the  following  summary  of  the  results  of  interstitial  injec- 
tions of  tincture  of  iodine,  practised  in  goitre  by  the  three  physicians: 

I/(  iS  jKitients. 

Goitre  of  all  classes  completely  cured 32 

Very  much  improved 9 

Improved 9 

Result  negative 2 

A  treatment  which  gives  such  good  results  will  certainly  soon  be  gen- 
erally adopted. 

Scrofida. — The  value  of  iodine  in  goitre,  which  is  generally  classed 
by  pathologists  among  strumous  affections  (though  wrongly,  as  we  think), 
led  Coindet  and  Brera  to  use  iodine  in  the  other  forms  of  scrofula:  en- 
gorgements and  ulcerations  of  the  lymphatic  ganglia  of  the  neck,  mesen- 
teric atrophy,  white  swellings,  etc.  {Biblloth.  unlv.  de  Geneve,  t.  XIV. 
and  XVL;  Arch.  f/en.  de  med.,  t.  II.,  p.  430).  More  lately  Sablairolles 
{JSfouv.  biblloth.  m'ed.,  t.  II.,  p.  385,  1823),  Benaven,  {Revue  med.,  1824, 
t.  IV.,  p.  83),  Gairdner  {Revue  med.,  t.  I.,  p.  490),  Manson  {Recherches 
sur  les  effets  de  Viode,  etc.,  London,  1825),  and  many  others,  whose  works 
are  analyzed  in  Bayle's  Bibliothtqxie  thcrapeutique,  have  also  praised  the 
virtues  of  iodine  in  scrofula.  But  Lugol,  physician  at  the  hospital  Saint- 
Louis,  has  certainly  done  the  most  to  popvilarize  its  use  in  scrofulous  dis- 
ease. He  published  in  1828  a  first  memoire  on  the  subject,  describing 
the  good  effects  of  iodized  baths,  which  he  preferred.  Among  169 
scrofulous  patients  treated  by  him  with  iodine  only  during  six  months,  in 
the  unfavorable  circumstances  which  are  usually  found  in  hospitals,  36 
were  perfectly  cured,  and  30  were  remarkably  improved. 

Lugol's  results  did  not  at  first  escape  the  charge  of  exaggeration.  It 
was  difficult  to  admit  that,  in  profoundly  cachectic  subjects,  with  severe 
and  old  alterations  of  the  bony  system,  iodine  had  the  privilege  of  cur- 


ALTERATIVES.  141 

ing  after  every  other  agent  in  the  materia  medica  had  failed;  and  further 
doubt  was  thrown  on  these  miracles  by  the  unlucky  fact  that  the  hospital 
Saint-Louis  seemed  to  be  their  only  stage. 

Nevertheless,  light  has  grown  in  these  twenty-five  years,  and  experi- 
ence has  spoken.  Doubtless  there  was  exaggeration,  and  even  mistakes 
were  committed,  as  happens  at  the  beginning  of  every  experimental  re- 
search. But,  let  us  not  fear  to  say  with  one  of  our  most  impartial  writers, 
that  when  we  see  the  advance  made  by  iodine,  and  the  increasing  part  it 
plays  in  the  air,  the  water,  and  the  soil,  Lugol  must  be  acquitted  of  too 
passionate  a  predilection  for  this  agent,  the  supreme  importance  of  which 
he  had  hardly  suspected. 

Surely  no  one  to-day  will  be  disposed  to  admit  in  iodine  that  specific 
and  almost  infallible  virtue  which  was  ascribed  to  it  indiscriminately  in 
all  forms  of  scrofula,  from  simple  adenitis  to  caries  of  bone  and  tubercu- 
lous degeneration  of  the  mesenteric  or  other  glands;  but,  on  the  other 
hand,  it  is  attested  that  the  materia  medica  possesses  no  more  potent 
modifier  to  combat  that  numerous  class  of  morbid  forms  which  depend 
upon  lymphatism;  nor  can  we  deny  that  in  many  cases  it  has  a  real  power 
over  the  scrofulous  diathesis  itself. 

Thus,  it  is  certain  that,  when  the  lymphatic  glands  are  not  changed 
into  tuberculous  matter,  and  when  the  period  of  inflammation  is  past,  the 
internal  and  external  use  of  iodine  produces  a  more  rapid  resolution  than 
any  other  remedy  can  effect.  It  is  the  same  with  articular  tumors,  before 
they  are  associated  with  tubercular  degeneration  marking  their  termina- 
tion, and  particularly  when  the  lungs  are  not  tuberculous. 

M.  Bazin:  "  Scrofule,"  3d  edition,  1861,  regards  iodine  as  an  excellent 
remedy  in  the  first  stage  of  scrofula;  he  thinks  it  capable  of  driving  of¥ 
or  ameliorating  the  secondary  symptoms.  He  uses  it  in  the  form  of 
antiscorbutic  syrup,  of  iodized  syrup  of  horse-radish,  and  syrup  of  iodide 
of  iron. 

In  scrofula  he  uses  externally  iodine,  iodide  of  potassium,  iodide  of 
lead,  and  iodide  of  sulphur.  For  the  symptoms  which  he  calls  ternary  or 
quaternary,  he  relies  on  cod-liver  oil  rather  than  iodine. 

Among  the  various  accidents  of  scrofula,  there  is  one  which  often  baf- 
fles treatment;  that  is,  chronic  adenopathy.  We  very  often  see  patients 
who  have  escaped  from  all  the  accidents  of  scrofula  and  regained  a  strong, 
sometimes  even  a  sanguine  constitution,  but  who  have  in  the  neck,  or  the 
angle  of  the  jaw,  or  at  the  level  of  the  parotid,  enlarged  glands,  not  pain- 
ful, the  volume  of  which  deforms  the  features  and  annoys  the.  possessor. 
At  this  period  iodine  given  internally  is  without  effect;  the  pomades  do 
not  act;  and  the  physician  often  gives  up  the  disease  to  itself.  We 
ought  to  mention  two  remedies  which  have  already  had  some  success;  the 
one  is  metallic  iodine  covered  with  a  layer  of  wadding  (Prieur:  Acad,  de 
medec,  1864),  or  the  iodized  cotton  of  M.  Mehu;  and  the  other,  electri- 
city, in  the  form  of  the  constant  current,  which  has  sometimes  produced 
very  good  results. 


142  THERAPEUTICS. 

Another  most  grave  scrofulous  affection,  caries  of  the  vertebras,  or 
Pott's  disease,  has  been  relieved  by  preparations  of  iodine.  Dr.  Patter- 
son, of  Dublin  {Journal  des  conn.  mecUco-chir.,  t.  I.,  p.  123),  M.  Abeille, 
and  we  ourselves,  have  seen  the  cure  of  such  cases. 

Lacteal  engorgement  of  lying-in  xoomen. — M.  Rousset,  of  Bordeaux, 
trusting  in  the  resolvent  powers  of  iodide  of  potassium,  has  given  it  to 
women  just  after  confinement,  who  do  not  give  suck  and  are  plagued 
with  full  breasts.  He  gives  it  in  the  dose  of  0%35  to  0'45  grammes  per 
day  (gr.  5'39 — G*93).  He  says  that  under  this  treatment  the  engorgement 
rarely  lasts  more  than  three  days  or  ends  in  an  abscess.  Billi,  of  Milan, 
claims  to  have  obtained  the  same  success  {Uulletin  de  therapeutique, 
1863,  p.  65). 

Iodized  injections, — Hydrocele. — In  the  past  twenty  years  iodine,  in 
the  form  of  injections,  has  won  an  important  place  in  surgery.  There  is 
scarcely  any  cavity,  natural  or  accidental,  into  which  this  remedy  has  not 
been  forced,  for  the  purpose  of  causing  adhesion  of  the  walls,  or  of  modi- 
fying the  inner  surfaces  and  producing  resolution  of  a  morbid  state  of 
the  organ,  whether  acute  or  chronic  inflammation,  or  vices  of  secretion,  etc. 

Of  those  who  have  most  aided  in  extending  this  method,  we  place  in 
the  first  rank  MM.  Velpeau,  and  Martin  of  Calcutta,  next  MM.  Boinet, 
Borelli  of  Turin,   Jobert  de  I^amballe,  Abeille,  etc. 

The  method  was  first  employed  in  surgery  for  injections  of  tincture  of 
iodine  into  the  tunica  vaginalis.  In  this  special  case  they  w^re  proposed 
and  praised  by  M.  Velpeau,  Martin  of  Calcutta,  O'Brien  ( Gazette  ined., 
1838),  Oppenheim  (Bidletin  de  chir.,  1839),  and  many  others. 

But  the  credit  of  the  initiative,  and  of  experiment  upon  a  grand  scale 
at  the  hospital  of  la  Charite,  is  due  to  Velpeau. 

Since  then  there  is  scarcely  a  surgeon  who  has  not  repeated  his  exper- 
iments with  advantage;  and  the  use  of  tincture  of  iodine  in  injections 
has  now  completely  supplanted  that  of  wine  in  the  radical  cure  of  hydro- 
cele. 

"  It  seems  to  me  proved,"  says  M.  Velpeau  {Annales  de  la  chirurgie 
fran^.  et  etrangere,  avril,  1843): 

"  1.  That  tincture  of  iodine  provokes  adhesive  inflammation  of  the 
closed  cavities  with  as  much  certainty  as  any  other  liquid. 

"  2.  That  it  involves  less  risk  of  purulent  inflammation  than  wine. 

"  3.  That  it  distinctly  aids  the  resolution  of  simple  engorgements  com- 
plicating dropsy. 

"  4.  That  if  it  enters  the  cellular  tissue,  it  cannot  cause  gangrenous 
inflammation." 

Encouraged  by  his  success  in  dropsy  of  the  tunica  vaginalis,  Velpeau 
has  injected  iodine  into  many  other  closed  cavities,  normal  or  accidental, 
containing  serum,  or  even  blood  in  an  altered  but  liquid  condition. 

He  even  ventured  to  inject  tincture  of  iodine  diluted  with  water  into 
the  synovial  sac  of  the  knee,  and  hernial  sacs  communicating  with  the 
great  peritoneal  cavity,  and  no  accident  followed. 


ALTERATIVES.  1 43 

The  surgeon  of  la  Charite  has  to-day  some  hundreds  of  observations, 
which  incontestably  prove  the  vakie  of  iodine  in  these  cases. 

He  commonly  uses  a  mixture  of  two  parts  of  water  to  one  of  tincture 
of  iodine.  M.  Jobert,  who  has  injected  into  purulent  cavities,  commonly 
uses  the  pure  tincture. 

A.  Berard  also  preferred  injections  of  iodine  for  hydroceles,  and,  in 
general,  for  the  affections  in  which  Velpeau  praises  it.  He  justifies  his 
preference  by  more  than  200  successful  cases.  He  has  five  times  injected 
iodine  into  the  femoro-tibial  articulation,  without  causing  serious  symp- 
toms.    He  uses  equal  parts  of  tincture  of  iodine  and  water. 

M.  Faures  ("  Comptes  rendus  de  la  Soc.  medic,  de  Toulouse,"  1861) 
has  repeated  the  procedure  of  Martin  of  Calcutta,  which  consists  in  sim- 
ply injecting  a  few  drops  of  tincture.  In  a  case  of  double  hydrocele  in  a 
canon,  the  cure  was  complete  on  the  tenth  day.  But  might  not  this 
method  cause  gangrene  of  the  scrotum  ? 

Ilydarthroses,  dropsy  of  the  hursce  mucosm,  artictdares  and  tcndinece. 
— Led  by  the  success  of  the  previous  treatment,  surgeons  and  veterinar- 
ians have  rivalled  one  another  in  making  these  injections  into  various 
closed  cavities,  natural  or  accidental.  Thus,  at  first  they  were  utilized  in 
various  sorts  of  serous  cysts  {Bidletin  de  therapeidique,  1841) ;  then  in 
certain  large  abscesses  {Gazette  niedicale,  1846). 

In  1847,  U.  Leblanc,  one  of  our  most  distinguished  veterinarians,  in 
concert  with  Dr.  Thierry,  made  iodized  injections  into  the  various  syno- 
vial tumors  of  horses;  they  find  that  the  inflammation  was  usually  mode- 
rate and  slightly  painful,  while  it  was  sufficient  to  prevent  the  return  of 
the  lesion. 

M.  Reynaud  regards  iodine  as  a  much  more  active  agent  than  ordinar}'^ 
resolvents,  and  free  from  the  inconveniences  of  other  modes  of  treat- 
ment. Long  before  MM.  Velpeau  and  Ricord  employed  tincture  of 
iodine  in  hydrocele,  it  was  used  at  the  naval  hospital  of  Toulon,  in 
dropsy  of  the  mucous  burs£e.  Within  a  few  days  the  complete  resolution 
of  old  voluminous  hygromas  is  almost  always  secured,  without  bad  con- 
sequences. If  there  is  inflammatory  swelling  of  the  neighboring  parts, 
this  is  relieved  by  proper  means;  afterwards,  the  patient  is  subjected  to 
a  somewhat  severe  diet,  the  limb  is  placed  completely  at  rest,  and  every 
morning  and  night,  or  three  times  a  day,  friction  is  made  with  8  grammes 
of  pomade  composed  of 

Iodide  of  potassium 8  grammes=  3  ii. 

Lard 30         "        =  §  i. 

Dissolve  the  iodide  in  a  little  water,  and  add  the  lard. 

After  each  friction,  the  part  is  covered  with  a  large  linseed-meal  poul- 
tice. Some  results  obtained  with  iodide  of  lead,  lead  us  to  think  the  lat- 
ter more  efficacious  than  iodide  of  potassium.  After  a  few  days,  the  skin, 
at  first  yellow,  then  brown,  wrinkles,  tans,  and  falls  in  scales.     The  tumor 


144  TIIEKAPEUTICS. 

grows  soft,  divides  into  several  lobules,  and  soon  disappears  wholly. 
There  remains  then,  at  the  point  which  it  occupied,  a  little  thickening, 
which  disappears  of  itself  after  a  few  frictions,  so  that,  at  the  end  of  the 
treatment,  the  part  is  restored  to  its  normal  state. — The  usual  duration  of 
this  treatment  is  two  weeks. 

M.  Cabissol  mentions  eleven  observations  which  fully  estabHsh  the  su- 
periority of  iodine  to  the  resolvent  metals  in  the  treatment  of  dropsy  of 
the  mucous  burstii  {Bull,  de  thenq).,  t.  XIV.,  fcvrier,  1838). 

Since  then,  the  little  tumors  called  ganglia  have  been  universally  treated 
by  injections  into  the  cyst  as  well  as  by  frictions  with  iodine.  The  pure 
tincture  is  commonly  used  for  the  injections.  Professor  Borelli,  of  Turin, 
has  been  among  the  most  successful  in  this  mode  of  treatment.  In  a  paper 
published  in  the  Sardinian  Gazette  mediccde  (1852)  he  quotes  some  obser- 
vations which  attest  its  efficacy  as  well  as  its  harmlessness. 

In  those  rather  frequent  cases  in  which  hydarthrosis  resists  internal 
and  external  treatment,  and  especially  blisters  applied  to  the  seat  of  swell- 
ing, injections  of  iodine  into  the  articular  cavity  offer  a  valuable  resource, 
which  must  not  be  neglected.  Some  surgeons,  including  Velpeau,  disre- 
garding the  danger  of  the  entrance  of  a  few  bubbles  of  air  into  the  articu- 
lar capsule,  puncture  with  a  very  fine  trocar;  but  most,  in  order  to  avoid 
this  accident,  however  trifling  it  may  be,  prefer  to  use  the  subcutaneous 
method.  Present  experience  has  shown  that  iodized  injections  made  into 
the  joint-cavities  according  to  the  rules  given  by  Velpeau,  Bonnet,  Abeille, 
Robert,  etc.,  commonly  involve  no  danger,  and  in  a  very  large  majority  of 
cases  produce  resolution  of  the  fluid  and  a  cure,  provided  the  disease  be  not 
complicated  by  deep  alterations  of  the  soft  or  hard  parts.  Some  good 
cases  of  M.  Robert's  have  latel}^  placed  this  beyond  question. 

At  the  beginning  it  was  thought  that  iodine  cured  by  provoking  ad- 
hesive inflammation,  but  Hutin's  recent  cases  tend  to  show  that  adhesive 
inflammation  is  usuallv  absent,  as  in  the  case  of  hydrocele,  and  that  the 
iodized  injections  simply  modify  the  synovial  membrane  in  a  specific  way, 
and  restore  the  normal  condition  of  the  secreting  surface.  If  adhesions 
occurred,  we  could  not  explain  how  articulations  which  remained  immov- 
able up  to  the  time  of  the  injection  should  regain  their  mobility  in  propor- 
tion as  the  effusion  recedes.  It  is  probable  that  the  same  thing  occurs 
which  has  been  seen,  not  only  in  the  tunica  vaginalis,  but  in  ovarian  cysts 
treated  with  iodized  injections,  in  which  the  autopsy  has  shown  a  complete 
absence  of  adhesions  between  the  surfaces,  or  only  partial  adhesions;  in 
which,  therefore,  the  cure  was  due  to  the  gradual  retraction  of  the  walls 
of  the  cyst  until  the  accidental  cavity  was  more  or  less  completely  obliter- 
ated. 

Iodized  injections  in  ascites. — Analogy,  often  a  sure  guide  and  always 
necessary,  easily  led  to  the  substitution  of  iodine  in  intra-peritoneal  injec- 
tions, in  place  of  alcohol  as  used  by  Bretonneau,  in  1820,  the  danger  of 
which  is  too  manifest.  MM.  Dieulafoy  and  Leriche,  in  1847,  introduced 
this  happy  modification,  and  have  published  very  detailed  accounts  show- 


ALTEEATIVES.  145 

ing  that  in  ascites,  apparently  dependent  on  simple  chronic  peritonitis, 
iodized  injections  may  produce  a  rapid  and  complete  cure.  M.  Leriche 
advises  that  only  one  injection  be  made  after  the  peritoneum  has  been 
emptied.     The  proportions  are  as  follows: 

Tincture  of  iodine 30  grammes. 

Iodide  of  potassium 4         " 

Distilled  water 250         " 

These  first  successes  soon  aroused  imitation,  and  cases  were  multiplied. 
MM.  Boinet,  Ore  of  Bordeaux,  and  Paul  Dard,  a  pupil  of  Tessier,  of  Ly- 
ons, have  published  important  papers  upon  their  own  practical  results,  in 
various  scientific  collections. 

From  the  considerable  number  of  observations  contained  in  these  ac- 
counts, there  results  a  fact  which  has  been  rather  neglected,  but  which 
demands  more  ample  verification:  the  fact  that  injections  of  iodine  into 
the  peritoneum  constitute  a  treatment  which  is  not  only  efficient,  but 
seems  almost  harmless,  when  executed  under  good  conditions  and  in  ac- 
cordance with  certain  rules. 

Experience  has  established  certain  indications  or  contra-indications 
which  must  be  attended  to.  Thus,  injections  of  iodine  are  not  only  use- 
less, but  dangerous,  when  ascites  is  a  symptom  of  an  organic  affection  of 
the  heart,  liver,  spleen,  kidneys,  etc. 

It  should  be  reserved  for  certain  rather  rare  cases  in  which  the  ascites 
is  due  to  chronic  peritonitis  or  a  simple  secretory  irritation  of  the  perito- 
neal membrane,  either  idiopathic,  or  consecutive  to  menstrual  disorders,  or 
a  neighboring  phlegmasia,  as  enteritis;  or,  where  the  ascites  is  consecutive 
to  an  alteration  of  the  blood,  a  cacliectic  state.  Let  us  add  that,  even  in 
these  cases,  the  injection  of  iodine  should  never  be  used  except  after  all 
the  usual  remedies  fail. 

If  the  ascites  is  very  voluminous,  a  previous  puncture  should  be  made 
to  lessen  the  extent  of  peritoneal  surface  and  the  extent  of  inflammation. 
It  is  recommended  not  to  empty  the  cavity  wholly,  but  to  leave  in  it  one 
or  two  quarts  of  serum,  in  order  to  diffuse  the  tincture  equally  and  pre- 
vent its  coming  in  direct  contact  with  the  irritant  liquid,  which  might  pro- 
voke a  fatal  peritonitis. 

The  entire  dose  of  fluid  injected  ought  not  to  exceed  250  grammes 
(  3  viii.).  The  injection  must  not  be  made  in  one  push,  but  insinuated 
gradually,  while  the  assistants  gently  knead  the  belly  so  as  to  assist  the 
mixture  of  the  remedy  with  serum,  and  insure  its  penetration  to  the  re- 
moter parts. 

Injection  of  iodine  into  the  pleural  cavit;/. — We  have  performed  this 
in  certain  cases  of  collection  of  pus  in  the  pleura,  when,  after  repeated 
punctures,  the  pus  tended  to  reproduce  itself  continually;  we  have  several 
times  succeeded  in  effecting  a  cure,  when  the  complication  with  tubercle 
was  absent.  {Bull,  de  la  Soc.  des  hdpitaux,  septembre,  1854.) 
10 


146  THER  APE  UTICS. 

Others,  including  MM.  Legroux,  Boinet,  Aran,  etc.,  have  repeated 
these  experiments,  and  the  successful  cases  are  now  so  numerous  and  well 
attested  that  the  accusation  of  rashness  must  be  withdrawn.  M.  Aran, 
emboldened  by  the  success  obtained  in  hjdrothorax  and  hydropneumo- 
thorax,  has  ventured  to  introduce  iodized  injections  into  the  pericardium, 
and  his  attempt  has  succeeded. 

Injection  of  iodine  in  sjnna  bifida. — Debout,  the  former  editor  of  the 
bulletin  de  therajyeutique,  concluded  a  report  made  to  the  Societe  de 
chirurgie,  in  1860,  in  the  following  words:  "Of  all  known  treatments  of 
this  vice  of  conformation,  that  by  injection  of  iodine  is  the  most  efficacious 
and  the  least  dangerous."  In  the  same  year,  Dr.  Coates,  of  Salisbury, 
used  iodine  injections' for  a  child  of  three  months,  affected  with  spina  bi- 
fida. He  drew  out  by  the  trocar  8  grammes  of  transparent  fluid,  and  in- 
jected the  same  quantity  (  3  ii.)  of  a  1^  per  cent,  solution  of  iodine.  On  the 
next  day  the  child  had  convulsions  of  the  hands  and  feet,  but  the  cure  was 
speedy  and  complete  at  the  end  of  two  months  ( The  Ijancet,  March  3, 1866). 

Similar  success  has  been  obtained  by  M.  Sezerie,  a  physician  at  Saint- 
Barthelemy  (Lot-et-Garonne)  (Acad,  de  medecine,  17  sept.,  18C1),  by  M. 
Caradec,  of  the  hospital  at  Brest  ( Union  medicale,  1867,  Nos.  26  and  30), 
and  M.  Roux  {Bulletin  de  t1ierapei(tiqne,  1869,  I.,  27). 

Ovarian  dropsy. — Thompson  ("  Elements  of  Materia  Medica  and  Ther- 
apeutics ")  gave  large  doses  of  iodine  (180  drops  daily,  taken  internally),  and 
cured,  as  he  says,  three  women  in  five.  Some  other  cases  have  since  been 
reported,  of  cure  of  ovarian  cysts  by  the  internal  use  of  iodine  combined 
with  frictions  upon  the  tumor.  These  results,  though  rare  and  exceptional, 
are  sufficient  to  lead  practitioners  to  attend  to  this  practice  instead  of  pre- 
maturely using  puncture  and  injections,  or  ovariotomy. 

To  Boinet  we  certainly  are  the  most  indebted  for  this  radical  treat- 
ment of  ovarian  dropsy.  The  debates  which  this  grave  question  excited 
some  years  ago  are  well  known;  we  shall  not  speak  of  them,  but  will 
simply  note  the  general  conditions  under  which  the  treatment  may  legi- 
timately be  undertaken.  Thus,  in  cases  where  the  cyst  is  unilocular,  or 
when  it  is  multilocular  and  contains  only  serous  or  sero-purulent  fluid; 
and  in  particular,  when  it  has  no  organic  complication,  whatever  the  size 
of  the  tumor  may  be,  puncture  followed  by  injection  of  iodine  may  offer 
chances  of  success.  Some  observations  quoted  by  Boinet  and  others 
assure  us  of  the  reality  of  a  more  or  less  complete  cure.  The  iodized  in- 
jections act  here  by  a  double  mechanism,  either  by  determining  adhesive 
inflammation  (which  is  much  contested)  or  by  exercising  a  quite  special 
modification  upon  the  secreting  surface  and  the  secreted  product.  What- 
ever be  the  nature  of  this  action,  observation  shows  that  the  effused 
liquid,  be  it  serous  or  purulent,  tends  to  improve  in  character  daily,  and 
to  lessen  in  amount  until  completely  dried  up.  At  the  same  time  the 
cyst  shrinks,  and  at  last  forms  merely  a  cellular  mass  without  a  cavity,  a 
sort  of  stump,  almost  inert.  These  are  the  most  favorable  cases — and 
quite  exceptional  ones. 


ALTEEATIVES.  147 

It  is  shown  by  experience  that  this  method  fails  almost  wholly,  and  is 
not  without  danger,  when  employed  for  multilocular  cysts,  with  very 
hard  and  thick  walls  and  considerable  cavities,  especially  if  the  liquid  is 
very  viscous  or  bloody.     It  is  then  prudent  to  avoid  it. 

An  infinity  of  conditions  are  required  in  order  to  obtain  these  good 
results;  and  a  very  special  modus  operandi  must  be  followed.  We  can- 
not do  better  than  to  refer  the  reader  to  the  raemoire  of  M.  Boinet  in  the 
Bulletin  de  therapeutique,  aoAt,  1852,  and  his  complete  treatise  entitled 
"  lodotherapie,"  in  which  these  conditions,  precautions  and  methods  are 
fully  stated — in  short,  everything  which,  after  a  correct  diagnosis,  is 
adapted  to  insure  success  (2d  edition,  I8G0). 

We  must  add  that,  in  this  very  delicate  question,  great  attention  must 
be  paid  in  future  to  the  valuable  statements  presented  at  the  late  aca- 
demic discussion.  While  on  the  one  hand  this  discussion  has  given  the 
victory  to  the  side  of  iodine  injections,  by  showing  that  under  favorable 
conditions  the  operation  is  nearly  free  from  danger,  and  usually  followed 
by  a  temporary  or  permanent  cure,  on  the  other  hand,  it  will  result  in 
making  certain  contra-indications  better  known  and  more  definite,  and 
will  have  the  very  good  effect  of  checking  physicians  in  that  reckless 
course  which  has  doubtless  proved  fatal  to  more  than  one  patient. 

Congestive  abscess. — One  of  the  most  important  uses  of  the  injection 
with  iodine  is  its  application  in  the  radical  cure  of  congestive  abscess. 
This  is  due  to  M.  Boinet,  who  in  1850  reported  to  the  Societe  de  chirurgie 
several  cures  by  injection  into  the  purulent  cavity  combined  with  the  use 
of  iodized  preparations  internally.  An  interesting  observation  of  this 
sort  was  published  in  the  Union  7nedicale  for  September,  1853,  by  Dr. 
Foucault  of  Nanterre;  the  case  was  one  of  congestive  abscess  with  fis- 
tulte,  of  eight  months'  date,  which  was  cured  in  two  months  by  iodized 
injections  and  the  internal  use  of  preparations  of  iodine. 

The  method  has  since  been  employed  by  a  great  number  of  physicians; 
we  have  obtained  the  best  results  from  it. 

Abscess  vjit/i  separation  of  skin/  Jistida  in  ano. — Boinet  has  certainly 
done  the  most  to  popularize  the  various  local  uses  of  iodine.  In  his  hands, 
injections  into  the  great  closed  cavities  left  by  abscesses,  with  separation 
of  skin,  became  a  powerful  remedy. 

He  subsequently  extended  this  method  to  fistula  in  ano,  and  in  a 
paper  read  in  1853  before  the  Academy  of  Sciences,  he  presented  obser- 
vations which  go  to  show  that  all  varieties  may  be  thus  cured,  the  blind 
or  incomplete,  the  complete,  deep  fistulas  with  burrows  and  separation 
of  the  intestine  and  fistulas  in  tuberculous  patients;  he  especially  likes 
this  treatment  in  those  sorts  of  fistula  in  which  incision  would  be  ineffec- 
tual or  dangerous,  for  example  those  which  go  deep,  or  depend  on  caries 
or  other  affection  of  the  ischium,  coccyx,  sacrum,  etc. 

If  these  results  are  confirmed,  as  certain  successful  trials  since  made 
by  others  permit  us  to  hope,  the  method  would  be  preferable  to  that  by 
incision  as  causing  less  danger  and  inconvenience;  it  does  not  prevent 


148  THERAPEUTICS. 

patients  from  attending  to  business,  and  it  spares  them  painful  dressings. 
If  the  treatment  fails,  it  never  aggravates  the  ailment;  hence  it  may 
fitly  be  tried  before  the  knife. 

Injections  into  the  hernial  sac. — To  conclude  what  we  had  to  say  about 
injections  into  closed  cavities,  we  will  add  that  some  physicians,  including 
M.  Jobert,  have  attempted  a  radical  cure  of  hernia  b}^  injecting  tincture 
of  iodine  into  the  interior  of  the  sac,  and  that  quite  a  number  of  success- 
ful attempts  have  been  obtained. 

Painting  xoith  ioditie. — If  iodine  is  so  useful  in  the  form  of  injections 
into  closed  cavities,  it  is  not  less  valuable  when  put  on  as  paint,  on  the 
outer  skin,  or  on  certain  accessible  parts  of  the  internal  integument. 

Painting  with  tincture  of  iodine  upon  the  skin  is  constantly  employed 
as  a  revulsive,  or  as  a  means  for  producing  absorption  of  the  drug,  and 
resolution  of  subjacent  inflammations.  The  chest  is  thus  painted  in  sub- 
acute affections,  as  slight  pleuris)%  or  pleurodynia,  partial  phthisis,  cir- 
cumscribed lobular  pneumonia  without  too  active  inflammatory  reaction. 

In  these  cases  the  revulsive  may  well  supplant  blisters,  of  which  it 
has  the  advantages  without  the  defects;  it  is  especially  adapted  to  women 
with  delicate  skins,  and  children,  and  in  general  to  nervous  subjects  who 
would  be  too  much  irritated  by  cantharides. 

Painting  with  the  tincture  is  often  indicated  at  a  certain  stage  of  pro- 
fuse pleuritic  effusion,  chronic  or  acute,  when  a  quantity  of  fluid  remains, 
upon  which  blisters  cease  to  act,  and  wlien  the  resorbent  activity  needs 
to  receive  a  fresh  impulse  after  a  period  of  arrest.  This  is  what  may  be 
often  seen  in  effusion  of  latent  type,  especially  in  connection  with  a  tuber- 
culous diathesis. 

The  same  application  may  be  usefully  made  to  the  abdominal  walls  in 
certain  affections  of  subacute  and  chronic  form,  particularly  congestion 
of  the  abdominal  viscera;  we  have  repeatedly  obtained  very  great  benefit 
in  engorgement  of  the  mesenteric  glands  in  children. 

Painting  with  tincture  of  iodine  is  often  used  in  affections  of  the 
joints,  as  at  the  close  of  acute  rheumatism  when  the  last  remains  of  syno- 
vial effusion  disappear  slowly;  more  often  in  chronic  arthritis  and  incipient 
white  swelling;  also  in  hydarthrosis  and  hygroma.  But  in  the  last  named 
cases,  the  action  of  the  tincture  is  usually  too  superficial,  and  in  general, 
insufficient;  it  must  be  replaced  by  a  more  energetic  agent,  that  is,  the 
caustic  solution  of  iodine. 

In  summary,  we  may  say  that  there  is  perhaps  no  part  of  the  skin  to 
which  this  topical  application  is  not  suited,  when  a  phlegmasia  or  inflam- 
matory engorgement  is  located  just  beneath,  or  in  its  neighborhood,  and 
demands  a  resolvent  treatment. 

^  Following  the  example  of  the  Belgian  physicians,  we  are  accustomed 
in  various  ophthalmias,  especially  ulcerative  or  granular  corneitis,  to  apply 
tincture  of  iodine  to  the  lid  or  on  the  forehead  and  temple  of  the  affected 
side. 

Diseases  of  the  skin. — The  preparations  of  iodine,  particularly  the 


ALTERATIVES.  149 

tincture,  have  the  remarkable  power,  when  applied  to  the  inflamed  skin, 
of  driving  away  the  inflammation  and  its  local  symptoms.  Thus  we  often 
succeed  in  aborting  erysipelas,  in  resolving  or  improving  adenitis  or  angio- 
leucitis,  which  threaten  to  spread,  and  even  to  arrest  the  evolution  of 
the  pustules  of  small-pox  in  certain  regions,  as  the  face.  Tincture  of 
iodine  may  thus  be  considered  an  excellent  antiphlogistic,  nearly  analo- 
gous to  nitrate  of  silver. 

Ophthalmia;  disease  of  the  lachrymal  passages. — Iodine  has  been 
used  here,  not  as  a  simple  counter-irritant,  but  by  virtue  of  its  being 
eliminated  through  the  tears.  M.  de  Beaufort  has  taken  advantage  of 
this  fact  to  treat  chronic  affections  of  the  lachrymal  passages  by  the  in- 
ternal use  of  iodide  of  potassium  in  the  dose  of  0'25  to  one  gramme  (gr. 
4 — 15).  A  speedy  improvement  has  followed  where  the  tears  contained 
iodine  [Bulletin  de  tlt'erap..,  1868,  1,  78).  We  will  mention  also  the  good 
effect  of  iodized  collvria  in  removing  maculee  of  the  cornea  (Castorani: 
Bullet,  de  therap.,  1868, 1,  p.  90). 

Affections  of  the  mucous  membranes. — In  spite  of  assertions  to  the 
contrary,  the  contact  of  tincture  of  iodine  with  the  mucous  membrane  is 
not  at  all  painful,  unless  some  point  of  solution  of  continuity  exists,  or 
the  membrane  is  stripped  of  its  epithelium.  Boinet  has  shown  that  the 
pharyngeal  and  buccal  mucous  membrane  may  be  painted  almost  without 
the  patient's  knowledge;  or  that  of  the  tonsils,  the  neck  of  the  uterus, 
the  vagina,  etc.;  on  the  condition  that  the  iodine  does  not  touch  the  ori- 
fices of  the  mucous  cavities  at  the  point  of  transition,  where  the  tissue  is 
infinitely  more  fine  and  sensitive,  and  pain  is  produced,  as  acute  as  when 
the  tincture  is  put  on  skin  deprived  of  its  epidermis,  or  a  recent  wound. 
Boinet  therefore  expressly  directs  that  nothing  but  the  mucous  membrane 
be  touched. 

He  also  says  with  much  reason  that  if  several  coats  are  laid  on  the 
same  place  desquamation  occurs,  as  it  does  in  the  skin,  and  that  subse- 
quent applications  will  certainly  cause  pain. 

Whatever  may  be  the  nature  of  an  affection  of  the  mucous  membrane 
of  the  mouth  or  the  pharynx,  whether  specific  or  not,  there  is  none  which 
has  not  been  advantageously  treated  with  iodized  applications.  Whether 
in  the  form  of  gargles,  washes,  or  painting  with  a  brush,  tincture  of  iodine 
has  done  signal  service  in  simple  or  gangrenous  stomatitis,  pultaceous, 
croupous  or  gangrenous  diphtheria,  and  granular  pharyngeal  angina, 
■which  is  always  so  obstinate.  We  may  say  the  same  in  relation  to  the 
various  ulcerative,  purulent,  gangrenous,  and  syphilitic  affections,  to  hos- 
pital gangrene,  and,  in  general,  all  septic  affections. 

M.  Boinet,  who  has  done  more  than  an\'  one  to  further  the  use  of  these 
topical  applications  in  the  greater  part  of  the  inflammations  of  the  mucous 
membrane,  constantly  derives  the  greatest  advantage  from  their  use  in 
granulations  and  ulcerations  of  the  neck  of  the  uterus,  and  praises  them 
especially  in  acute  or  chronic,  simple  or  virulent  vaginitis.  In  this  case 
he  paints  the  whole  vulvo-uterine  canal  from  the  neck  of  the  womb  to  the 


150  THERAPEUTICS. 

introitus  vaginae  with  pure  tincture  of  iodine.  One  application  is  usu- 
ally sufficient.  As  a  measure  of  precaution,  in  the  case  of  severe  blen- 
norrhagia,  he  carefully  paints  the  labia  majora  and  minora  and  their  folds; 
and  ends  by  making  an  injection  into  the  anterior  part  of  the  urethra  with 
a  mixture  of  equal  parts  of  tincture  of  iodine  and  water,  taking  care  to 
prevent  its  entrance  into  the  bladder.  This  treatment  seems  to  him 
preferable  to  cauterization  with  nitrate  of  silver,  both  as  being  much  less 
painful,  and  as  much  more  j^rompt,  easy,  and  efficacious  (  Union  niedicale, 
septembre,  1853). 

When  the  ulcerated  surfaoe  of  the  neck  of  the  womb  is  fungous,  and 
bleeds  at  the  least  touch,  when  the  entire  os  tincte  and  part  of  the  canal 
of  the  neck  are  affected,  the  neck  and  even  the  body  are  seen  enlarged 
and  engorged.  In  this  condition  cauterizations  with  nitrate  of  silver  are 
no  longer  sufficient,  and  tincture  of  iodine  is  necessary  (Gallard:  bulletin 
de  th'erapeutique,  30  juillet,  18G5). 

In  our  opinion  there  is  no  such  resolvent  in  uterine  and  peri-uterine 
engorgement. 

Chronic  dysentery. — Dr.  Delioux  (  Union  medicale,  1853,)  used  iodine 
in  rectal  injections  to  relieve  clironic  dysentery.  By  thus  directly  modi- 
fying the  surface  of  the  mucous  membrane,  he  has  obtained  remarkable 
results.  His  injections  contain  10 — 30  grammes  (  3  iiss. —  5  i.)  of  tincture, 
1 — 2  grammes  (gr.  15 — 30)  of  iodide  of  potassium  to  render  it  soluble, 
and  200 — 250  grammes  of  water  (  3  vi. — viii.).  The  affection  was  cured  or 
much  relieved  in  10  of  the  12  cases  reported  in  his  paper;  in  two  cases 
he  failed,  but  without  aggravating  the  trouble.  He  states  that  these  in- 
jections usually  produce  only  slight  colics,  easily  quieted  by  the  injection 
of  laudanum- water  if  necessary.  He  remarks  the  ease  with  which  iodine 
might  be  introduced  into  the  system  through  the  rectum. 

We  see  that  iodine  has  been  of  the  greatest  use  in  a  great  many  dis' 
eases  of  the  serous  cavities,  the  external  and  internal  integument.  This 
field  of  usefulness  constitutes  one  of  the  most  precious  conquests  of  ther- 
apeutics. And  yet,  great  and  rapid  as  has  been  this  extension  of  its 
powers,  we  can  easily  see  that  new  applications  remain  to  be  made,  and, 
without  doubt,  more  than  one  useful  result  to  be  gained. 

Owing  to  its  remarkable  antiseptic  and  resolvent  powers,  iodine  may 
find  its  application  wherever  there  is  an  ill-conditioned  ulcer  to  clear  up, 
or  a  vicious  secreting  surface  to  modify,  or  a.  chronic  refractory  phlegma- 
sia to  resolve.  Whatever  be  the  seat  of  the  lesion,  whether  the  surface 
of  the  skin  or  the  most  remote  part  of  the  mucous  membrane,  or  the 
depths  of  a  serous,  synovial,  or  other  cavity,  we  are  authorized  to  expect 
everything  from  iodine,  if  its  topical  action  be  never  so  little  available. 

Thus,  as  experience  shows,  the  materia  medica  has  scarcely  an  exter- 
nal agent  which  is  at  once  more  efficient  and  more  harmless  than  iodine. 
For  this  reason  we  do  not  hesitate  in  placing  it  by  the  side  of  nitrate  of 
silver,  as  one  of  the  most  precious  agents  in  substitutive  medicine. 

Syphilis. — The  powerful  resolvent  action  of  iodine,  its  influence  on 


A  LTER  ATI  YES.  151 

nutrition,  led  to  the  hope  that  it  might  be  made  useful  in  constitutional 
syphilis.  For  some  years  iodide  of  mercury  had  been  used  for  this  pur- 
pose, and  is  found  to  be  of  most  value  in  the  chronic  forms  of  syphilis. 
"Was  the  success  of  the  new  remedy  attributable  to  the  mercury,  the  iodine, 
or  to  the  combination  of  both  ?  Wallace,  of  Dublin,  has  touched  this 
question,  and  shows  that  iodine  is  as  useful  as  mercury  in  the  treatment 
of  constitutional  syphilis  {Jour,  des  comiais.  taed.-chir.,  t.  IV.,  p.  157). 
Of  142  patients  treated,  6  had  iritis,  6  engorgement  of  the  testicle,  10 
various  diseases  of  the  bones  and  the  joints,  97  cutaneous  syphilides,  20 
lesions  of  the  mucous  membrane  of  tiie  mouth,  nose,  and  throat;  finally, 
iodine  was  given  to  three  pregnant  women  to  prevent  infection  of  the 
foetus.  The  preparation  used  is  the  mistura  hydriodatis  potasste,  con* 
taining  8  grammes  (  3  ii-)  of  iodide  to  250  grammes  (  3  viii.)  of  distilled 
water.  Adults  take  a  tablespoonful  of  this  mixture  four  times  a  day, 
making  60  grammes  (  3  ii.)  or  2  grammes  (gr.  30)  of  the  iodide. 

We  were  the  first  to  try  Wallace's  method,  in  1835,  at  Paris,  and 
proved  its  good  effects.  But  M.  Ricord,  at  the  head  of  a  venereal  hospi- 
tal, made  the  trial  on  a  larger  scale,  and,  as  a  result,  he  placed  iodide  of 
potassium  in  the  same  rank  as  mercury,  as  an  antisyphilitic.  He  made 
the  most  use  of  it  in  what  he  calls  the  tertiary  accidents.  He  places  the 
symptoms  which  yield  to  iodide  of  potassium  in  the  following  order  : 
deep  tubercles  of  the  skin  and  mucous  membrane;  tubercles  of  the  cellu- 
lar tissue,  commonly  called  gummous  tumors;  jDcriostosis,  caries,  exosto- 
sis, osteocopic  pains,  etc. — The  doses  which  he  uses  are  far  larger  thari 
those  of  Wallace;  he  begins  with  one  gramme  per  day  in  a  draught  (gr, 
15)  and  increases  to  4  grammes  (  3  i.)  without  injurious  effects.  Bullock 
has  published  facts  which  confirm  the  statements  of  Wallace,  Ricord,  and 
ourselves  {France  med.,  fevr.,  1839). 

This  is  a  proper  place  to  compare  the  relative  power  of  mercury  and 
iodine  over  the  symptoms  of  constitutional  syphilis. 

Ricord  considers  mercury  the  true  specific  in  secondary  symptoms, 
and  iodide  of  potassium  as  of  no  real  value,  save  in  tertiary  symptoms. 

This  view,  while  correct  in  general,  becomes  inexact  when  stated  ab- 
solutely. 

Surely  mercury  does  not  retain  in  tertiary  symptoms  the  efficacy  which 
it  unquestionably  possesses  in  the  secondary.  Yet,  the  most  positive  facts 
attest  that  even  tlien,  it  is  not  only  not  powerless,  but  even  sometimes 
superior  to  iodine. 

Many  physicians  have  used  it  with  full  success,  as  we  have  done,  not 
only  in  certain  periostoses  which  form,  the  transition  from  the  second  to 
the  third  stage,  but  even  in  old  exostoses,  and  other  phenomena  which 
are  evidently  tertiary.  And  conversely,  iodine,  though  generally  more 
effective  in  the  tertiary  accidents,  is  inferior  to  mercury  in  certain  ul- 
cerations of  the  pharynx,  and  some  other  manifestations  of  secondary 
syphilis. 

The  treatment  of  visceral  syphilis  is  not  so  well  defined  as  that  of  the 


152  THERAPEUTICS. 

secondary  and  tertiary  symptoms.  Iodide  of  potassium  is  usually  first 
employed,  and  sometimes  cures.  Oppolzer,  of  Vienna  {Schmidt's  Jahr- 
biicher,  186G,  4),  and  Leudet,  of  Rouen,  have  found  it  very  useful  in  he- 
patic syphilis;  Rollet  ('"Traite  des  maladies  veneriennes,"  18GG),  in  pul- 
monary syphilis;  and  Gros  and  Lancereaux  ("  Des  affections  nerveuses 
syphilitiques,"  1861),  as  well  as  Zambaco  (lb.,  18G2),  in  nervous  syphilitic 
affections.  Nevertheless,  when  improvement  does  not  occur  promptly,  and 
the  chief  affection  is  cerebral,  we  recur  to  mercury. 

Before  Wallace,  and  before  iodine  had  been  used  in  syphilis,  Girtan- 
ner  gave  burnt  sponge  for  venereal  ulcers  of  the  throat.  In  18:21,  Mar- 
tini, of  Lubeck,  substituted  iodine  for  burnt  sponge  in  the  treatment  of 
chancres  of  the  pharynx,  following  Coindet,  who  had  made  the  same  sub- 
stitution in  the  case  of  goitre.  He  has  since  often  given  iodine  and  iodide 
of  potassium  in  these  grave  forms  of  syphilis,  and  has  been  pleased  with 
the  results  {Journ.  des  connais.  med.-chir.,  t.  I.,  p.  90).  Dr.  Henri  Gou- 
raud  informs  us  that  he  has  used  it  with  advantage  in  chronic  anginae  not 
connected  with  syphilis.  We  have  several  times  obtained  results  with  it, 
under  like  circumstances,  which  we  had  failed  to  secure  by  otiier  treat- 
ment. 

While  it  is  incontestable  that  iodide  of  potassium  renders  as  impor- 
tant services  in  constitutional  syphilis  as  mercury,  we  cannot  deny  that 
the  union  of  the  two  has  immense  value.  Experience  has  pronounced  to 
that  effect.  The  protiodide  of  mercury,  used  on  a  large  scale  by  Biett, 
and  subsequently  by  all  physicians;  the  double  iodide  of  mercury  and 
potassium  recommended  by  Puche  {Hull,  therap.,  mars,  1839),  hold  a 
very  high  rank  in  the  treatment  of  venereal  disease.  They  are  given  in 
pills,  in  the  dose  of  1 — 10  centigrammes  (gr.  0'15 — 1'5),  combined  with  a 
little  opium  to  mitigate  their  irritating  qualities. 

^imenorrhcea. — The  increase  which  occurs  in  the  menstrual  discharge 
during  the  administration  of  iodine,  for  whatever  reason  given,  induced 
Brera  to  try  the  remedy  in  amenorrhoea.  The  facts  reported  by  him  in 
the  "Saggio  Clinico,"  Ai'ch.  gen  de  med.,  t.  II.,  p.  439  et  seqq.,  are  not 
very  conclusive,  nor  are  those  of  Coindet  and  Sablairolles.  We  have 
tried  the  remedy  in  amenorrhoea,  and  have  obtained  some  results  like  those 
of  Brera  {Journ.  des  cotmaiss.  med.-chir.,  t.  I.,  p.  74).  But  after  some 
years  of  experience,  we  have  come  to  the  following  general  conclusions: 

In  chlorotic  girls,  iodine  produces  no  result  unless  iron  has  previously 
been  used;  but  when  the  blood  is  restored,  iodine  plainly  increases  the 
flow,  and  makes  it  appear  sooner  than  if  left  to  nature.  In  women  of 
high  complexion,  with  scanty  and  painful  menstruation,  iodine  increases 
the  flow  of  blood,  but  increases  at  the  same  time  the  pain  and  sometimes 
causes  metritis.  It  is  really  useful  in  women  of  good  color,  with  scanty 
but  not  painful  menses.  In  amenorrhoea  proper,  iodine  must  be  used  a 
long  time;  25  or  30  drops  of  tincture  being  given  every  day,  or  at  least 
one  tablespoonful  of  Wallace's  mixture  of  hydriodate  of  potassa,  for  two 
or  three  months. 


ALTERATIVES.  153 

M.  Boinet  has  noted  a  curious  fact  relative  to  the  emmenagogue  prop- 
erty of  iodine:  when  he  has  painted  it  upon  the  neck  of  the  womb  and 
the  vagina,  he  has  almost  uniformly  provoked  the  menstrual  flow.  This 
led  him  to  touch  the  cervix  and  part  of  the  vagina  in  certain  cases  of  dif- 
ficult or  suppressed  menstruation;  and  he  says  that  he  usually  brought 
back  the  menses  by  this  plan.  He  draws  a  very  prudent  inference;  it  is 
always  well  to  abstain  from  this  act  in  pregnancy. 

Leiicorrhoea. — It  is  singular  that  a  remedy  which  so  manifestly  pro- 
vokes the  menstrual  discharge  should  have  been  recommended  by  Brera, 
Gimelle  and  Sablairolles,  in  the  treatment  of  leucorrhoea;  but  its  effect 
can  be  explained  as  little  as  it  can  in  blennorrhagia.  Pierrequin  has 
used  iodide  of  iron  with  success  in  this  affection  (Merat  and  de  Lens, 
t.  III.,  p.  635).     In  blennorrhoea,  Ricord  praises  it  highly.    • 

Gout,  rheumatism. — M.  Gendrin  speaks  highly  of  the  internal  and 
external  use  of  iodine  in  gout,  saying  that  in  the  majority  of  cases  it  dis- 
pels the  sharpest  acute  attack.  He  uses  it  in  chronic  gout,  both  to  re- 
solve nodosities  and  chalk-stones,  and  (internally  given)  to  modify  the 
general  health.  Valentin,  of  Nancy,  had  already  recommended  calcined 
sponge  in  gout  {Journ.  gener.  de  m.ed.,  t.  CIV.,  p.  59). 

We  may  add  that  iodide  of  potassium  has  more  than  once  rendered 
us  services  in  atonic  gout  which  we  could  have  obtained  from  no  other 
drug. 

Dr.  Aubrun  has  used  iodide  of  potassium  with  advantage  in  acute  or 
subacute  articular  rheumatism,  especially  in  cases  where  the  patient's 
weakness  forbade  bleeding  {Gaz.  med.,  1843). 

Dr.  Izarie  published  in  the  Union  tnediccde  (April,  1852)  some  facts 
tending  to  show  the  value  of  the  same  remedy  in  high  doses  (4 — 8 
grammes,  3  i. — ij.)'  ^^^  sciatica.  The  recovery  was  so  rapid  that  it  could 
hardly  be  attributed  to  chance. 

Some  years  ago  we  had  an  excessively  nervous  patient,  affected  with 
one  of  the  most  painful  and  obstinate  sciaticas,  w-hich,  after  resisting  va- 
I'ious  treatment,  especially  large  blisters  and  morphia,  yielded  rapidly  to 
iodide  of  potassium  in  rather  large  doses. 

These  rheumatic  sciaticas,  cured  by  iodide  of  potassium,  naturally  as- 
sociate themselves  with  the  sciatic  and  other  neuralgias  which  are  success- 
fully treated  with  the  same  remedy.  Dr.  Gerard,  of  Lyons,  has  reported 
several  instances  of  the  last  sort  in  the  Union  medicate,  mai,  1852. 

We  would  remark,  that  while  iodide  of  potassium  may  have  been  use- 
ful in  certain  rheumatic  neuralgias,  its  efficacy  is  still  better  established 
in  those  of  syphilitic  origin.  Thus,  when  we  meet  with  certain  rebellious 
neuralgias,  with  nightly  exacerbations,  we  must  not  forget  to  examine 
carefully  whether  some  connection  with  constitutional  syphilis  is  trace- 
able, that  we  may  immediately  resort  to  the  specific  treatment.  We  will 
add,  that  even  if  in  doubt,  there  is  no  objection  to  using  a  remedy  which 
is  suitable  to  more  than  one  morbid  condition. 

Gravel. — After  rheumatism  and  gout,  we  must  mention  gravel  as  sus- 


154  THERAPEUTICS. 

ceptible  of  benefit  from  the  preparations  of  iodine.  We  know  that  some 
physicians,  including  M.  Henry  de  Saint-Arnoult,  have  observed  old  cases 
of  gravel  with  severe  kidney  symptoms,  in  which  a  prolonged  use  of  the 
iodide  in  small  doses  gave  the  happiest  results.  It  is  surely  possible  that 
iodide  of  potassium,  by  its  special  properties,  has  a  direct  action  on  the 
morbid  secretion  which  characterizes  gravel,  but  perhaps  the  chief  cause 
of  its  efficiency  depends  on  the  influence  of  the  medicine  on  the  arthritic 
diathesis,  of  which  gravel  is  often  a  mode  of  manifestation. 

Sjjasmodic  Asthma. — Some  physicians  in  England  and  France  have 
recommended  iodide  of  potassium  in  the  treatment  of  spasmodic  asthma. 
In  France,  M.  Aubree,  a  physician  and  druggist  at  Bury  (Charente),  has 
earnestly  advised  its  use.  He  makes  an  elixir  with  decoction  of  polygala, 
syrup  of  opium  and  iodide  of  potassium,  and  obtains  very  good  results  by 
insisting  on  protracted  treatment.  In  our  own  experience  we  have  found 
its  efficacy  truly  remarkable  in  several  cases.  In  what  way  does  it  act  ? 
Is  it  by  its  anti-arthritic  property,  as  we  just  said  in  regard  to  gravel,  or 
by  a  quite  special  action  peculiar  to  asthma  spasmodicum  ?  This  is  a 
question  which  we  cannot  decide,  but  the  fact  is  very  positive  (Trousseau: 
"  Ciinique  medicale,"  3d  ed.,  t.  II.,  p.  476). 

Aneurism  of  tJie  aorta. — Dr.  Chuckerbutt}^  a  physician  at  Calcutta, 
has  published  two  observations  in  which  iodide  of  potassium,  in  the  dose 
of  O'G  grammes  daily,  greatly  relieved  patients  suifering  from  aneurism 
of  the  aorta  {Bull,  de  th'erap.,  1862,  t.  LXIII.) 

Pulmonary  Phthisis. — The  use  of  iodine,  by  inhalation,  is  not  quite 
new.  Proposed  in  1828  by  Dr.  Berton,  for  chronic  bronchitis  and  pul- 
monary phthisis,  it  was  tried  at  the  Children's  Hospital,  b}-  Baudelocque, 
who  thought  iodine  vapor  more  hurtful  than  beneficial  to  the  phthisical; 
and  since  then  nothing  more  has  been  heard  of  it  in  France. 

But  in  England,  the  method  was  taken  up  by  Murray  and  L.  Scuda- 
more,  who  said  they  had  obtained  good  results  from  it,  while  at  the  same 
time  Pereira  stated  that  he  tried  iodized  inhalations  in  the  treatment  of 
pulmonary  phthisis  without  finding  any  marked  improvement. 

The  remedy  had  fallen  into  general  neglect,  when  Piorry  called  atten- 
tion to  the  use  of  vapors  of  iodine  and  to  the  internal  administration  of 
iodine  and  the  iodides  in  this  disease.  Dr.  Chartroule,  following  Piorry's 
indications,  has  paid  special  attention  to  this  branch  of  therapeutics,  and 
especially  to  the  use  of  iodine  in  the  form  of  vapors.  He  causes  the 
patient  to  inhale  the  vapor  either  from  cigarettes  or  from  a  special  appa- 
ratus, which  is  very  like  that  used  by  Cottereau  for  his  inhalations  of 
chlorine.  M.  Danger  has  since  presented  to  the  Academic  des  sciences, 
an  apparatus  of  the  same  sort,  very  simple  in  mechanism,  by  the  aid  of 
which  the  patient  may  inspire  pure,  dry,  warm  air  charged  with  iodine  in 
the  state  of  vapor,  which  in  this  state  of  purity  penetrates  to  the  furthest 
bronchial  ramifications  (August,  1853). 

Others,  following  Piorry,  sinipl}^  place  the  patient  in  an  iodized  atmos- 
phere by  keeping  by  his  bedside  saucers  which  contain  a  certain  amount 


ALTERATIVES.  155 

of  this  volatile  substance.  A  weak  tincture  of  iodine  is  generally  placed 
on  the  thorax,  in  addition  to  the  above,  and  iodine  and  the  iodides  are 
also  taken  internally. 

Whether  this  remedy,  under  these  various  forms,  acts  as  a  direct 
modifier  of  the  bronchi  or  as  a  reconstituent  of  the  entire  system,  it  is 
certain,  on  the  one  hand,  that  it  has  a  favorable  influence  upon  lympha- 
tism  and  the  strumous  diathesis,  and  that,  on  the  other  hand,  in  a  con- 
siderable number  of  cases  it  has  rendered  important  services  to  tubercu- 
lous patients,  either  by  improving  that  concomitant  bronchorrhoea  which 
exhausts  most  phthisical  persons,  or  by  reanimating  the  appetite  and  the 
strength  of  those  enervated  and  cachectic  patients  who  fill  our  hospitals. 

But  to  suppose  that  iodine,  in  vapor  or  otherwise,  has  accomplished 
firm  and  complete  cures,  or  that  the  process  of  tuberculization  has  been 
arrested  indefinitely,  is  to  make  a  claim  which  seems  to  us  unsupported 
by  present  experience. 

Laryngitis,  bronchitis,  catarrh. — While  the  virtue  of  iodine  is  still 
doubtful  in  phthisis,  it  is  not  so  in  bronchorrhoea  or  catarrh  of  the  mucous 
membrane  of  the  bronchi,  where  it  is  plainly  useful,  as  it  is  in  catarrh  of 
the  urethra,  the  vagina  and  the  uterus.  We  confidently  recommend  in- 
halations of  iodine,  in  various  forms,  in  the  treatment  of  certain  cases  of 
laryngitis,  and  bronchitis  in  a  chronic  state,  in  which  we  have  man}'^  times 
seen  their  efficacy. 

Typhoid  or  putrid  fever. — We  have  seen  that  iodine  possesses  the 
most  remarkable  antiseptic  powers.  It  was  therefore  quite  natural  to 
seek  to  utilize  these  properties  in  the  various  diseases  marked  by  svmp- 
toms  of  putridity  or  septic  poisoning  of  the  blood.  Boinet  and  Aran  had 
already  made  some  trials  of  iodized  preparations  in  typhoid  fever,  with 
quite  good  success;  but  their  results  had  not  become  much  known  when 
Dr.  Magonty  formulated  the  method  more  precisely.  He  gives  to  adults 
three  or  four  spoonfuls  a  day  of  a  solution  containing  5  centigrammes 
(gr.  0'75)  of  iodine,  3  grammes  (gr.  30)  of  iodide  of  potassium,  and  240 
grammes  (nearly  |  viii.)  of  distilled  water.  At  the  same  time  he  ordered 
two  injections  per  diem,  each  containing  5  centigrammes  of  iodine,  50 
centigrammes  (gr.  7'5)  of  iodide,  and  125  grammes  (  3  iv.)  of  distilled 
water.  There  is  only  one  objection  to  the  results;  they  were  altogether 
too  good,  since  of  21  patients,  2]  are  claimed  as  cured. 

M.  Regis,  following  the  same  plan,  calmed  the  ataxic  symptoms  in  an 
epidemic  of  typhoid  fever,  by  giving  every  day  4  drops  of  tincture  of 
iodine  in  a  soothing  mixture  ( Gazette  hebdomadaire,  1865). 

In  spite  of  this  success,  we  are  certainly  indisposed  to  propose  the 
iodine  method  as  a  general  plan  of  treatment  in  typhoid  fever.  But  on 
the  other  hand,  as  we  see  no  reason  to  proscribe  it  absolutely,  it  seems 
to  us  rational  to  use  it  in  certain  forms,  where  putridity  or  septicemia 
prevails  from  the  outset. 

For  the  same  reason,  we  should  be  inclined  to  appeal  to  this  remedy 
in  another  disease,  very  different  in  its  septic  nature  and  its  severity;  we 


156  THERAPEUTICS. 

refer  to  puerperal  fever,  especially  in  its  epidemic  form.  Some  cases  of 
cure  under  this  treatment  have  been  cited;  these,  though  inconclusive, 
and  the  known  impotence  of  medicine  in  this  terrible  malady,  form  a 
sufficient  ground  for  making  further  trials  of  iodine. 

Tuhercalar  meningitis,  acute  and  chronic  hydrocephalus. — More  than 
twenty  years  ago,  Roeser  recommended  this  remedy  in  acute  hydrocepha- 
lus; since  when,  following  his  example,  a  certain  number  of  English  phy- 
sicians of  great  authority,  as  Copland,  Evanson,  Wood,  John  Coldstream 
etc.,  have  pronounced  in  favor  of  this  treatment.  More  recent)}-,  M.  Laf- 
fore,  of  Agen,  and  M.  Scoepf  Mercei,  of  Pesth,  have  affirmed  its  value  with 
a  confidence  bordering  on  enthusiasm.  M.  Laffore,  in  a  paper  presented 
to  the  Academic  de  medecine,  at  Paris,  stated  that  iodide  of  potassium  in 
the  dose  of  3  grammes  (gr.  45)  had  succeeded  in  seven  cases  of  tubercular 
meningitis,  several  of  which  presented  the  symptoms  of  the  third  period. 
But  the  experiments  made  by  the  same  physician  at  the  children's  hospi- 
tal, at  Paris,  had  no  such  favorable  results. 

Having  been  repeatedly  invited  by  physicians  who  had  confidence  in 
the  remedy,  and  being  in  despair  of  the  disease,  almost  invariably  fatal  as 
it  is,  we  have  many  times  given  iodide  of  potassium  in  the  cerebral  fever 
of  children,  especially  in  tubercular  meningitis,  both  in  and  out  of  hospi- 
tals. But  we  never  obtained,  we  will  not  say  success,  but  even  an  im- 
provement sufficienth'  marked  to  encourage  our  attempts.  We  know  that 
other  physicians  claim  to  have  been  more  successful,  but  it  may  be  of  use 
to  observe  that  there  are  certain  causes  of  error  or  illusion  which  it  is  not 
always  easy  to  avoid. 

Chronic  f/lande^'s. — Although  it  be  not  allowable  to  identify  chronic 
glanders  in  the  horse  with  tubercular  phthisis  in  man,  the  usual  incurable 
nature  of  glanders  gives  some  value  to  the  case  reported  by  Thompson, 
and  ought  to  induce  physicians  and  veterinarians  to  employ  iodine  in  hope- 
less cases.     His  case  is  as  follows: 

A  glandered  horse  took  150  drops  of  strong  tincture  of  iodine  three  or 
four  times  a  day  in  water.  This  was  continued  regularly  for  six  weeks, 
during  which  time  not  less  than  450  drops  were  given  daily,  and  often 
more  than  500  or  GOO.  The  benefits  of  this  solution  became  evident  in  a 
few  days,  and  at  the  end  of  seven  weeks  the  animal  w^as  almost  entirely 
cured.  Four  j-ears  later,  he  had  had  no  relapse. — Was  the  glanders  well 
established?  According  to  Dr.  Thompson,  the  symptoms  were  very  evi- 
dent ( Gaz.  med.,  1847,  No.  42). 

Alhumiyiuria. — Dr.  Monfeuillard  ("  These  de  Paris,"  18G9)  has  published 
very  remarkable  results  obtained  with  iodine.  The  first  successful  cases 
■were  treated  by  Dr.  Baudon,  of  Mouy  (Oise).  The  latter  at  first  prescribed 
iodide  of  iron  in  the  dose  of  0*2 — 0*4  grammes  (grs.  .3 — 6),  and  afterwards 
iodide  of  potassium  in  doses  increasing  from  2  to  20  grammes  (grs.  30 — 
300)  per  day.  But  in  these  enormous  quantities,  iodide  of  potassium  was 
ill  borne  and  had  but  little  effect.  Dr.  Bourdon,  at  the  Charite,  obtained 
the  same  results  much  more  simply  with  12  drops  of  tincture  of  iodine  per 


ALTERATIVES.  157 

day,  given  after  the  manner  of  Gueneau  de  Mussy  in  a  starchy  potion, 
such  as  rice-water.  Finally,  Dr.  Monfeuillard  has  used  iodide  of  calcium 
in  the  dose  of  1 — 3  grammes  (gr.  15 — 45).  The  two  latter  preparations, 
iodide  of  starch  and  iodide  of  calcium,  caused  a  much  more  rapid  disap- 
pearance of  albumin  from  the  urine.  Of  the  13  patients  whose  cases  are 
reported  by  Dr.  Monfeuillard,  13  were  cured  and  the  other  greatly  im- 
proved.    These  results  are  very  encouraging. 

Mercurial  salivation. — Dr.  Knod,  a  few  years  ago,  communicated  to 
Hufeland's  journal  the  discovery  which  he  had  made  of  the  property  pos- 
sessed by  iodine,  of  arresting  salivation.  Kluge  employed  this  method 
with  the  greatest  success  in  17  patients  at  the  Charite  hospital  in  Berlin. 
The  pain  and  swelling  of  the  glands  and  the  salivation  ceased  after  five 
or  six  days,  and  even  syphilitic  ulcers  rapidly  improved.  The  dose  was 
10  centigrammes  (gr.  1:^)  per  day,  and  was  raised  by  degrees  to  20.  The 
formula  used  was  the  following: 

1^ .     Iodine 25  centigrammes  (grs.  3"8). 

Dissolve  in 

Alcohol 8  grammes  (  3  ii-)- 

And  add 

Cinnamon-water 80  grammes  (  3  xx.). 

Syrup  of  sugar 16  grammes  (  3  iv.). 

Give  daily,  at  first  4  half -spoonfuls,  afterwards  4  entire  spoonfuls  of 
the  mixture  (Hufeland:  '•Journ.,"  ap.,  1833,  and  Journ.  cles  connaiss. 
tned.-chir.,  t,  I.,  p.  89). 

The  salivation  of  pregnancy  is  notoriously  obstinate  in  the  majority  of 
cases.  We  have  read  with  interest  an  observation  published  bv  Dr.  Le- 
maestre,  in  which  a  salivation,  so  abundant  as  to  threaten  to  exhaust  the 
patient,  and  rebellious  to  all  other  remedies,  was  quite  rapidly  cured  by 
iodide  of  potassium  given  in  the  form  of  pastilles.  Four  or  five  of  these 
were  given  daily,  to  be  allowed  to  dissolve  in  the  mouth,  and  the  saliva  to 
be  swallowed. 

Injurious  effects  of  mercury  and  lead. — MM.  Natalis  Guillot  and  Mel- 
sens  have  found  that  iodide  of  potassium  causes  mercurial  tremor  to  cease, 
and  moderates  or  causes  to  disappear  the  severe  affections  often  observed 
in  lead-workers.  They  gradually  raise  the  dose  of  iodide  of  potassium 
to  4  or  even  6  grammes  (  3  i. — iss.)  per  diem. 

In  a  more  recent  paper  {Journ.  de  chimie  medicale,  1849,  p.  13G),  M. 
Melsens  has  proposed  iodide  of  potassium  in  the  treatment  of  chronic  pois- 
oning by  the  compounds  of  lead  and  mercury.  Under  the  influence  of  the 
remedy  these  compounds  are  rapidly  eliminated  by  the  urine.  It  must  be 
given  in  small  doses,  since  a  large  quantity  of  lead  or  mercury,  set  free  at 
once  in  a  soluble  form,  might  cause  acute  poisoning. 

Loosening  of  the  teeth. — There  is  no  more  frequent  cause  of  the  loosen- 
ing of  one  or  several  teeth  than  inflammation  of  the  alveolar  membrane. 
Sometimes  the  origin  of  this  is  in  the  tooth  itself,  or  the  gums;  at  other 


158  THEEAPEUTICS. 

times  it  originates  from  the  periosteal  covering  of  the  alveolus,  and,  reach- 
ing the  root  of  the  tooth  and  the  gum,  causes  much  pain  and  swelling; 
the  tumefaction  of  the  tissues  pushes  the  root  of  the  tooth  out  of  the  al- 
veolus, and  a  tooth  thus  loosened  not  rarely  falls  out,  though  it  may  have 
no  trace  of  alteration. 

This  affection  is  usually  accompanied  by  an  acute  pain  and  a  discharge 
of  pus  between  the  gum  and  the  inflamed  periosteum.  The  treatment  is 
often  confined  to  the  application  of  a  few  leeches  to  the  painful  part,  and 
in  severe  cases  to  deep  incisions  in  the  gums  and  the  inflamed  periosteum. 
"  One  of  these  patients,"  says  Graves,  "  was  treated  by  this  method;  and, 
though  he  was  in  the  hands  of  a  skilled  surgeon  and  an  eminent  dentist, 
he  lost  successively  a  left  canine  and  an  upper  molar  tooth.  The  extrac- 
tion of  these  gave  him  momentary  relief,  but  in  a  few  days  the  pain  re- 
turned as  bad  as  ever,  and  no  remedy  was  offered  except  to  pull  out  all 
his  teeth  as  fast  as  they  became  loose.  After  various  attempts  he  came 
to  me,  when,  recollecting  that  I  had  successfully  treated  him  the  year  be- 
fore with  hydriodate  of  potassa  for  a  periostitic  affection  of  the  sternum 
and  the  ribs,  I  directed  him  to  take  8  grains  three  times  a  day;  he  began 
to  improve  directly,  the  pain  and  inflammation  disappeared  at  once,  and  in 
ten  days  his  teeth  were  perfectly  solid.  The  periostitis  was  rheumatic  in 
its  nature;  his  constitution  was  healthy,  and  he  was  only  forty-four  years 
old." 

But  we  must  add  that  in  this  severe  gingivitis  with  loosening  of  the 
teeth  the  internal  use  of  iodine  is  usually  insufficient,  and  must  be  rein- 
forced by  topical  treatment.  In  this  case  Marchal,  of  Calvi,  orders  the 
aqueous  solution  of  Lugol,  in  preference  to  the  tincture.  The  topical  use 
of  iodine  is  doubly  valuable  here,  for,  in  addition  to  its  essential  and  cura- 
tive action  upon  the  affected  part,  it  acts  also  as  an  antiseptic,  correcting 
the  bad  odor  of  the  mouth. 

Coryza. — In  chronic  coryza,  and  especially  in  oza?na,  we  must  recom- 
mend iodine.  It  is  used  in  watery  solution  or  tincture,  applied  within 
the  nasal  fossa3  by  a  pencil  or  by  injection.  For  the  same  purpose,  from 
8  to  13  pinches  of  the  following  powder,  prepared  by  Dr.  Sobrier,  may 
be  taken  daily  with  advantage:  iodide  of  sulphur,  30  centig.  (gr.  4|); 
subnitrate  of  bismuth,  4  grammes  (3i.);  powdered  licorice,  8   grammes 

(3ii.). 

Nervous  diseases. — "What  are  we  to  say  of  the  experiments  of  M. 
Manson  in  the  treatment  of  chorea  and  various  paralyses  ?  The  author's 
facts  are  not  wholly  without  interest,  but  are  far  from  conclusive.  We 
ought,  however,  to  mention  that  small  doses  of  tincture  of  iodine  have 
been  proposed  as  one  of  the  best  remedies  for  the  vomiting  of  pregnancy. 

We  close  with  a  curious  statement  made  by  M.  Donne  in  1826,  namely, 
that  tincture  of  iodine  is  the  best  remedy  in  poisoning  by  morphia, 
strychnia  and  the  other  vegetable  alkaloids.  In  this  case  there  are 
formed  compounds  which,  according  to  Donn6,  have  no  injurious  action. 
But  these  facts  need  confirmation. 


ALTERATIVES.  159 

Exophthalmic  goitre. — M.  Gueneau  de  Mussy  relates  four  cases  of 
prompt  and  almost  unexpected  relief  by  the  use  of  iodide  of  starch,  in 
hypertrophic  goitre.  He  gives  from  3  to  6  drops  of  tincture  of  iodine, 
three  times  a  day,  to  be  poured  into  a  littLe  glass  of  rice-water  at  the 
moment  it  is  to  be  swallowed. 

The  first  case  is  one  of  a  gardener  affected  with  a  three-lobed  hyper- 
trophic goitre  passing  under  the  sterno-mastoid  muscles  and  threatening 
suffocation.  By  this  treatment,  the  dose  never  exceeding  18  drops  of 
tincture  daily,  the  patient  was  cured  in  two  months.  The  second  case  is 
that  of  the  son  of  the  preceding,  whose  goitre  was  less  advanced,  and 
was  cured  likewise.  Tlie  third  was  that  of  a  chambermaid;  the  cure  was 
equally  rapid.  The  fourth  is  a  case  of  exophthalmic  goitre  in  a  patient 
under  M.  Gueneau  de  Mussy  at  the  Hotel-Dieu;  at  the  end  of  a  fortnight 
her  neck  was  one  centimetre  (j^g-  of  an  inch)  less  in  circumference,  and  in 
a  month,  one  centimetre  and  a  half,  when  she  left  the  hospital  and  was 
not  seen  again. 

lODOFOEM. 

Goitre. — In  1843  Bouchardat  recommended  iodoform  as  a  substitute 
for  tincture  of  iodine  and  iodides,  and  gave  it  in  pastilles  and  pills.  In 
1848,  Glover,  professor  of  materia  medica  at  the  university  of  Newcastle- 
on-Tyne,  followed  his  example,  curing  two  women  who  had  goitre  by  in- 
ternal and  external  treatment  combined.  He  gave  it  internally  in  the 
dose  of  30 — 45  centigrammes  (gr.  4"6 — 7)  a  day  in  3  or  4  ^dIIIs,  making 
inunction  upon  the  tumor  at  the  same  time  with  a  pomade  containing 
iodoform  (  Union  medicale,  1858,  p.  198). 

Ulcers. — In  1853  Righini  of  Novara  discovered  that  iodoform  was  an 
excellent  application  for  causing  atonic  ulcers  to  heal,  and  that  under  its 
influence  wounds  wliich  had  no  tendency  to  heal  were  speedily  and  hap- 
pily modified.  The  same  results  were  obtained  at  Paris  by  M.  Lailler  at  the 
hospital  Saint-Louis,  and  by  M.  Besnier  {Bulletin  de  therapeutique,  1867), 
M.  Fereol  cured  atonic  and  varicose  ulcers  in  a  very  short  time  by  this 
means  (Societe  de  therapeutique,  20  mars,  1868).  M.  Labrie  used  it  for 
children  to  dry  up  pale  sores  left  by  blisters  which  did  not  heal  (These  of 
M.  Decuignicres,  Paris,  1872). 

Similar  observations  were  made  by  M.  Maillard  ("  Th^se  de  Paris," 
1868),  A.  Guerin,  Nieskowski  ("Th^se  de  Paris,"  1871),  and  M.  Petiteau 
("These  de  Paris,"  1871);  the  last  particularly  emphasises  the  success 
which  he  has  seen  under  M.  Fereol's  treatment  during  the  war,  in  gunshot 
wounds. 

A  question  here  arises:  By  what  process  of  mechanism  does  iodoform 
act  on  these  ulcers  ?  Is  it  simply  because  the  drug,  being  in  the  form  of 
powder,  acts  as  a  mechanical  absorbent  ?  This  is  hardly  probable,  for  the 
same  sores  when  dressed  with  powder  of  lycopodium  or  starch  did  not 
change  their  appearance.     Is  it  because  it  is  composed  of  crystals,  which 


160  THERAPEUTICS. 

act  as  irritant  bodies?  To  solve  the  problem  M.  I.ailler  dressed  a  patient's 
sy23hilitic  sores  upon  one  side  with  iodoform  powder,  and  upon  the  other 
with  talc;  the  result  was  very  different  in  the  two  cases.  To  ascertain 
whether  the  action  was  due  to  the  presence  of  iodine,  M.  Lailler  dressed 
some  sores  with  the  tincture  of  iodine  and  iodide  of  potassium,  and  failed 
to  obtain  as  good  results  as  when  iodoform  was  used.  We  are,  then,  re- 
duced to  think,  with  Righini,  that  its  efficacy  depends  in  part  upon  its 
relieving  the  pain  of  ulcers;  that  is,  its  anodyne  action  (a  +  oSvvrj,    pain). 

From  these  results,  we  can  easily  credit  the  prompt  improvement  in 
scrofulous  ulcers  which  is  reported  by  MM.  Maitre,  Humbert,  Moretin, 
Jules  Simon  and  Petiteau. 

Cancer. — The  alterant,  resolvent  and  anodyne  action  of  iodoform  ex- 
plains the  origin  of  its  use  in  dressing  ulcerated  and  painful  cancers  and 
cancroids.  M.  Bouchardat  recommended  it  in  1857,  and  from  that  time 
a  great  many  cancerous  patients  were  treated  by  this  remedy.  Debout 
remarked  that  it  produced  in  women  affected  with  uterine  cancer  a  sen- 
sation of  calm  and  comfort  (Bull,  de  therapeutique,  185T);  Greenlach  of 
St.  Bartholomew's  hospital,  and  Nunn  of  Middlesex  {Lancet,  1866)  made 
the  same  remark,  and  since  then  a  large  number  of  French  pliysicians, 
among  whom  we  will  name  Demarquay  {Hull,  de  therapeutique,  1867,  t. 
I.,  p.  399),  Woelker  {Ihid.,  t.  IL,  p.  493),  Lailler,  Maillard,  Petiteau, 
Decuigni^res.  These  good  effects,  which  we  have  also  obtained,  particu- 
larly in  cancroid  of  the  uterus,  have  one  further  advantage:  that  they  have 
led  to  the  employment  of  iodoform  in  painful  ulcers  which  were  on  the 
point  of  being  given  up,  but  which  were  not  cancerous  since  they  were 
cured. 

Fissure  of  the  amis. — M.  Moretin,  observing  that  a  suppository  of 
iodoform  introduced  into  the  rectum  considerably  lessened  the  sensibility, 
formed  the  idea  of  applying  it  to  the  treatment  of  fissure;  he  was  success- 
ful; and  several  successful  cases  have  since  been  treated  by  ourselves, 
and  by  MM.  Lailler  (hospital  of  Lourcine,  1859,  and  later  at  Saint-Louis), 
Fereol,  Nieskowski,  and  Petiteau.  It  is  a  remedy  to  be  tried  before  using 
forced  dilatation,  which  always  succeeds,  but  is  objectionable  to  patients. 

Visceralgia  (of  the  rectum,  vagina,  prostate,  bladder,  uterus,  teeth, 
etc.). — The  anodyne  effects  obtained  by  Moretin  in  the  case  of  the  rec- 
tum naturally  led  to  a  trial  of  suppositories  of  iodoform  in  painful 
spasmodic  affections  of  the  prostate  and  bladder  (Moretin).  M.  Hillai- 
rait  has  used  it  to  relieve  the  pain  of  piles;  M.  Marotte,  in  vaginismus; 
and  M.  Demarquay,  to  diminish  the  meteorism  which  accompanies  uterine 
affections. — M.  Lailler  has  made  a  paste  of  it,  to  fill  the  cavities  of  carious 
teeth  and  relieve  the  pain. 

Soft  chancre. — The  daih-  use  of  powdered  calomel  in  this  affection 
gave  rise  to  the  notion  of  using  powdered  iodoform,  which  has  had  great 
success  at  the  hospitals  Saint-Louis,  of  the  Midi,  and  of  Lourcine  (Lail- 
ler, F^r^ol,  Nieskowski,  Petiteau,  Isard,  Fournier,  Simonet.  Verneuil,  Gos- 
selin).     But  we  must  not  forget  that  the  treatment  is  hardly  practicable, 


ALTERATIVES.  161 

except  in  hospitals.  In  fact,  the  odor  is  so  penetrating  that  it  impreg- 
nates not  only  the  breath  and  the  clothes  of  the  patient,  but  his  whole 
room,  and  sometimes  the  entire  house,  smell  of  it  very  perceptibly.  It  is 
impossible  to  treat  a  person  secretly  "with  such  a  remedy,  and,  as  the  odor 
is  pretty  well  known,  it  is  very  compromising.  A  patient  whom  we  were 
treating  with  iodoform,  having  the  rashness  to  show  himself  at  a  public 
ball,  was  soon  an  object  of  attention  on  the  part  of  those  near  him,  and 
had  to  retire  in  haste. 

SyjyhUls. — Iodoform  seems  to  have  no  effect  on  hard  chancre;  but  the 
case  is  different  with  ulcerous  syphilides,  and  M.  Fereol  has  succeeded 
very  well  by  powdering  them  with  iodoform,  and  MM.  Petiteau  and  Isard 
report  similar  observations.  M.  Nieskowski  thought  he  had  succeeded 
quite  remarkably  in  onychia  syphilitica;  but  it  is  probable  that  he  began 
to  ti'eat  it  when  already  in  process  of  cure,  as  M.  Fournier,who  made  the 
same  trial  at  the  Lourciue  Hospital,  did  not  succeed. 

Finally,  Aran  cured  mercurial  stomatitis  with  iodoform.  But  we 
doubt  if  chlorate  of  potassa  will  be  abandoned  for  iodoform  in  this  affec- 
tion. 

Cod-Liver  On.. 
Therapeutic  Action. 

Rachitis. — The  effect  of  this  remedy  in  rachitis  is  so  evident  that  it 
would  deserve  a  high  rank  in  therapeutics  for  this  alone. 

The  four  cases  reported  by  Schenck  are  full  of  interest.  A  child  of 
two  years,  rachitic,  unable  to  stand,  took  half  a  tablespoonful  of  the  oil 
morning  and  evening,  and  was  perfectly  cured  when  he  had  taken  250 
grammes  (  ?  viii.).  Another  could  walk  at  the  age  of  twelve  months,  but 
soon  after  became  rachitic,  and  lost  the  power  of  standing;  he  took,  at 
the  age  of  two,  three  teaspoonf uls  of  the  oil  a  day,  and  was  cured  after 
taking  300  grammes  (  3  x,).  A  third,  who  was  very  well  during  the  first 
year  of  his  life,  had  all  the  symptoms  of  rachitis  in  the  second;  he  had 
walked  very  well,  but  now  had  lost  the  power  of  standing.  He  was  cured 
after  taking  oOO  grammes  of  the  oil:  a  teaspoonf ul  three  times  a  day. 
The  fourth  case  is  still  more  convincing.  A  little  boy  walked  alone  at 
the  age  of  one  year;  his  knees  soon  after  swelled,  the  spine  became  twisted, 
and  the  poor  child  lost  the  power  of  walking.  All  the  remedies  had  been 
tried  in  vain,  when  Schenck  employed  cod-liver  oil,  giving  half  a  table- 
spoonful  morning  and  night.  The  child  was  perfectly  cured,  excepting 
a  slight  deviation  of  the  vertebral  column,  after  taking  520  grammes 
(nearly  3  xviii.). 

The  testimony  of  Dr.  Fehr  deserves  quoting:  "The  striking  effect  of 
this  remedy,"  says  he  (Hecker's  Annaley^,  July,  1829,  p.  346),  "  is  manifested, 
not  only  after  a  change  in  diet,  or  the  beginning  of  fine  weather,  or  the 
commencement  of  a  period  of  growth,  but  very  often  after  one  or  two 
weeks.  The  teeth,  often  black  and  loose,  become  clean  and  firm.  Oliil- 
11 


162  THEEAPEUTICS. 

cireii  who  could  not  extend  their  legs,  and  who  uttered  loud  cries  when 
they  were  stood  upright,  begin  to  stand,  and  soon  to  walk,  provided 
they  are  of  a  proper  age  or  have  previously  walked.  Their  digestion 
improves,  the  stomach  becomes  more  supple,  especially  in  the  hepatic 
region.  The  excessive  or  deficient  appetite  ceases  with  the  acidity  of  the 
stomach;  the  ribs,  however  distorted,  resume  their  natural  form;  respira- 
tion becomes  free  and  easy,  the  legs  become  straight,  and  often  the  teeth 
appear  promptly,  etc." 

M.  liretonneau,  ignorant  of  the  scientific  studies  of  cod-liver  oil  which 
were  making  in  Germany,  was  led  to  try  it  in  rachitis  in  the  following- 
way:  a  Dutch  merchant  had  established  himself  at  Tours,  and  took  Bre- 
tonneau  for  his  physician.  One  of  his  children  became  exceedingly  rachi- 
tic, and  when  the  learned  practitioner  had  tried  the  usual  remedies  in 
vain,  the  father  said  that  the  eldest  of  his  children  had  had  the  same  com- 
plaint, and  had  been  cured  in  Holland  by  fish-oil  taken  as  a  popular  rem- 
edy. M.  Bretonneau  tried  the  same  remedy  for  his  little  patient,  and 
with  such  incredibly  rapid  success  as  to  astonish  him.  He  tried  it  for 
other  rachitic  children;  and  while  making  his  experiments,  he  was  pleased 
to  see  that  his  success  was  corroborated  by  that  of  the  German  writers 
whom  we  have  just  quoted.  We  might  add  the  testimony  of  Stapletou 
{Anjiales  de  la  Societe  de  niedecine  de  Gand),  Avho  cured  children  and 
adults  of  rachitis  by  large  doses  of  cod-liver  oil. 

Repeating  the  experiments  of  Schenck,  Fehr,  and  Bretonneau,  we 
have  convinced  ourselves  that  cod-liver  oil  acts  very  quickly  in  rachitic 
children,  and  is  most  serviceable.  Having  for  some  time  been  at  the  head 
of  a  children's  hospital,  we  have  given  it  many  times  to  rachitic  patients, 
and  have  often  obtained  a  success  more  speedily  than  we  had  hoped. 

Sometimes,  after  four  or  five  days  of  treatment,  the  acute  pains  in  all 
the  limbs  cease;  and  the  bones,  which  could  be  bent,  often  regain  a  great 
part  of  their  solidit}'  in  a  fortnight. 

A  woman  with  osteomalacia  in  an  extreme  degree,  who  could  not 
move  a  limb,  completely  recovered  the  firmness  of  her  skeleton  in  two 
months  of  treatment;  we  have  often  seen  her  since,  and  her  health  has 
always  been  perfect. 

Until  long  experience  had  given  us  certainty  of  diagnosis,  we  con- 
founded rachitis  with  scrofula,  as  many  physicians  do.  But  while  scrof- 
ula is  so  often  betrayed  by  tubercular  lesions,  rachitis  seems  to  exclude 
tubercles,  at  least  in  so  far  as  that,  in  our  children's  hospital,  rachitis  is 
rarely  complicated  with  tubercle,  which  is  found  in  almost  all  children 
who  die  of  any  chronic  disorder. 

We  used  also  to  confound  two  very  distinct  diseases,  tubercular  mes- 
enteric atrophy  and  ascites  symptomatic  of  rachitis.  It  is  important  to 
know  that  in  the  majority  of  children  affected  with  rachitis,  the  liver  is 
hypertrophied,  and  a  serous  effusion,  often  extensive,  into  the  peritoneum 
occurs;  this  effusion  is  absorbed  with  the  greatest  facility  while  the  rach- 
itis is  getting  well;   and   inexperienced  physicians  who   have   diagnosti- 


ALTERATIVES.  163 

cated  tabes  mesenterica  imagine  they  have  cured  this  dread  malady,  so 
rarely  recovered  from,  with  cod-liver  oil.  Let  us  add  before  leaving  the 
subject,  that  rachitis  is  a  disease  which  most  commonly  begins  during  the 
second  year  of  life;  while  tuberculous  mesenteric  disease  is  a  rare  affec- 
tion in  children  at  the  breast — so  rare,  in  fact,  that  we  have  made  but 
one  or  two  autopsies  of  such  cases  in  several  years,  at  our  hospital. 

Scrofula. — Though  cod-liver  oil  does  not  possess  the  incontestable — 
almost  miraculous  virtue  in  scrofula  which  is  almost  unanimously  accorded 
to  it  in  rachitis,  it  is  no  longer  possible  to  deny  its  real  influence.  But  this 
influence  is  less  marked  and  less  certain  in  some  forms  than  in  others. 

It  is  a  singular  fact,  that  in  general  the  strumous  affection  is  usually 
modified  favorably  by  the  oil  when  it  is  located  in  the  fibrous  and  bony 
tissues,  as  in  certain  white  swellings,  and  caries,  even  when  it  has  pro- 
duced a  cachectic  general  condition  by  excessive  and  proti'acted  suppura- 
tion; while  in  cases  where  the  disease  is  manifested  in  the  form  of  chronic 
engorgements  of  glands,  and  especially  in  adenitis  with  tubercular  degen- 
eration, the  action  is  less  certain. 

On  the  other  hand,  when  scrofulous  adenitis  followed  by  suppuration 
has  deeply  impaired  the  constitution  by  very  prolonged  dischai'ges,  cod- 
liver  oil  resumes  its  advantages,  and  gives  the  most  obvious  and  happy 
results.  The  explanation  of  this  curious  fact  will  be  given  at  the  end  of 
this  article.  It  is  the  same  with  the  dermatoses,  ophthalmia,  and  otitis, 
when  allied  to  strumous  cachexia. 

Among  the  severest  of  the  dermatoses  which  are  cured  by  cod-liver  oil 
we  will  place  impetigo,  the  malignant  scrofulidte,  and  especially  lupus. 
Every  one  knows  of  the  wonderful  cures  obtained  by  MM.  Emery,  Dever- 
gie,  Gibert,  Bazin,  etc.,  in  the  latter  disease,  by  means  of  very  large 
doses  of  the  oil — 200  to  300  grammes  (  §  vii. — x.,  nearly)  per  day. 

Finally,  in  mesenteric  tabes  with  tubercular  affection  of  the  mesen- 
teric glands,  cod-liver  oil  counts  some  successes;  but  these  are  more  nu- 
merous when  the  abdominal  affection,  principally  characterized  by  ascites 
or  tympanites,  is  dependent  on  rachitis,  as  is  so  often  observed. 

Phthisis  pulmonalis. — The  success  which  many  physicians  have 
claimed  in  glandular  scrofula  has  induced  others  to  try  cod-liver  oil  in  a 
much  graver  manifestation  of  the  scrofulous  diathesis,  in  pulmonary  con- 
sumption. 

Pereira,  of  Bordeaux,  was  the  most  ardent  promoter  of  this  treatment. 
We  would  take  leave  to  say,  that  in  the  memoir  which  he  read  before  the 
Academie  des  sciences,  he  reported  so  large  a  number  of  cures,  and  exalt- 
ed the  power  of  the  oil  so  much,  that  his  enthusiasm  suggested  scepti- 
cism. We  have  repeated  his  experiments,  and  others  have  done  the  same; 
and  while  in  a  certain  number  of  cases  we  have  obtained  a  notable  im- 
provement of  symptoms,  we  must  add  that  in  the  immense  majority,  cod- 
liver  oil  has  failed,  as  do  all  remedies,  whether  empirical  or  rational, 
which  have  ever  been  tried.  The  question,  however,  does  not  seem  to  us 
finally  settled,  particularly  as  our  principal  experience  has  been  with  hos- 


1G4  THEKAPEUTICS. 

pital  patients,  that  is,  under  conditions  which  were  perhaps  not  the  most 
favorable  for  a  decision. 

Since  then  the  experiment  has  been  made  on  the  largest  scale;  in 
phthisis,  and  in  many  other  diseases,  the  remedy  has  been  almost  a  mat- 
ter of  course.  But  the  results  have  been,  as  one  might  have  expected, 
entirely  contradictory;  some  being  in  favor  of  the  curative  or  beneficial 
effect  of  cod-liver  oil  in  phthisis,  while  others  attested  a  very  slight  efh- 
cacy,  or  absolute  powerlessness.  The  extreme  divergence  of  opinion 
which  still  reigns  in  regard  to  this  grave  question  seems  to  us  largely  due 
to  a  cause  which  ought  to  be  mentioned:  the  fact  that  cod-liver  oil  has 
generally  been  given  for  pulmonary  phthisis  in  too  empirical  a  maimer. 

At  the  beginning  of  phthisis  the  oil  renders  important  service  when 
we  find  tubercles  in  the  first  stage  in  a  very  limited  region  of  the  lung, 
without  active  and  dominant  inflammation,  without  symptoms  of  phthisis 
properly  speaking,  and  everything  seems  as  yet  local,  except  that  the  gen- 
eral functions  begin  to  be  a  little  languid.  It  is  then  necessary  to  act; 
for  it  is  probable  that  emaciation  will  soon  commence,  and  be  followed  by 
hectic;  tuberculous  pneumonia  will  soon  follow,  and  the  second  stage  of 
phthisis  may  be  close  at  hand. 

In  this  case  we  advise  to  begin  by  giving  to  the  lungs  a  shock  to  re- 
lieve congestion  and  produce  resolution — by  an  emetic,  30  grains  of  ipe- 
cac powder  and  two  centigrammes  (gr.  0'3)  of  tartar  emetic  mixed  and 
made  into  three  equal  doses,  to  be  taken  very  early  in  the  morning, 
fasting,  at  intervals  of  a  quarter  of  an  hour.  Two  days  later,  cod-liver  oil 
may  be  commenced;  to  be  taken  at  the  beginning  of  meals. 

The  patient  must  take  exercise,  for  the  oil,  taken  in  a  state  of  idle- 
ness and  seclusion,  acts  badly,  does  not  fatten,  and  develops  neither  the 
nervous  nor  the  muscular  element. 

This  analeptic  should  not  be  taken  more  than  two  weeks  in  a  month: 
otherwise,  it  fatigues  and  saturates  the  digestive  tract,  acts  badly,  and 
destroys  its  own  future  career.  Its  real  value  must  be  economized  by  not 
wasting  it,  and  by  returning  to  it  often.  A  dessertspoonful  before  each 
meal  is  the  smallest  dose  that  can  be  taken,  and  two  before  each  meal 
followed  by  a  mixture  of  black  coffee  and  wine  of  bark  are  a  quite  suffi- 
cient dose. 

Cod-liver  oil  is  something  more  than  a  fatty  substance ;  it  is  a  substance 
intermediate  between  a  food  and  a  medicine.  It  is  for  this  reason  that  it 
should  be  given  in  the  cases  of  which  we  now  speak.  What  proves  this 
is  the  fact  that  fatty  foods  act  with  much  less  energy  than  cod-liver  oil, 
however  they  be  taken,  and  in  however  large  quantities.  This  places 
a  natural  distinction  between  this  truly  medicinal  oil  and  the  fatty 
foods. 

Cod-liver  oil  has  not  only  an  analeptic,  but  an  unquestionable  pectoral 
virtue;  in  many  phthisical  patients  it  calms  the  cough  quickly  and  makes 
breathing  stronger  and  deeper. 

When  the   oil   is  well  borne,  the  patients  grow  fat   rapidly,  but  the 


ALTERATIVES.  165 

other  forces,  muscular  strength  and  htematosis,  by  no  means  increase  in 
proportion.  The  patients  feel  this,  and  the  dynamometer  proves  it.  The 
increase,  however,  of  muscular  force  and  hiematosis,  occurs  later,  even 
when  the  use  of  the  oil  has  been  suspended. 

The  eye  of  the  patient  regains  lustre;  the  complexion  brightens;  he 
feels  muscular  force  increase,  and  the  dynamometer  shows  that  the  mus- 
cles are  richer  and  more  contractile.  A  certain  rise  in  the  scale  of  organic 
life  has  occurred.  A  substance  assimilable  to  the  tissues  has  formed  fat, 
which  seems  to  be  a  mininum  of  assimilative  result,  but  really  contains 
all  that  is  necessary  to  rise  in  the  scale  of  the  organic  elements.  In  fact, 
it  is  promoted  to  higher  and  more  noble  organic  functions;  it  becomes 
muscle  and  nervous  cell.  It  is  very  probable  that  these  processes  are  ac- 
complished in  the  lymphatic  and  circulatory  apparatus. 

The  efficacy  of  cod-liver  oil  depends  on  conditions'  which  are  not 
enough  appreciated.  To  act  well,  it  must  be  well  burnt.  This  is  doubt- 
less the  reason  why  it  succeeds  much  better  in  phthisical  patients  who 
exercise  than  in  those  who  cannot  leave  their  room  or  bed.  Those  who 
take  it  must  be  made  to  walk  as  much  as  possible  in  the  open  air.  For 
this  reason  we  give  it  much  less  in  the  hospital.  Patients  confined  to  the 
bed  or  room  almost  always  have  fever;  and  the  oil  is  much  less  successful 
when  fever  is  present. 

Although  the  remedy  is  contraindicated  by  a  very  marked  fever,  it  is  not 
so  when  the  patient  presents  only  that  sub-hectic  frequency  of  pulse  with 
simple  febrile  exacerbation  in  the  evening,  remitting  in  the  morning.  Such 
patients  may  and  ought  to  go  out;  and  if  borne  by  the  digestive  organs 
the  oil  is  useful  (Pidoux  :  "  Etudes  generales  et  pratiques  sur  I3,  phthisie," 
1873;   and  "  Traitement  compare  de  la  phthisie,"  Union  medicale,  18G9). 

For  these  reasons  we  incline  to  the  opinion  of  Dr.  Milller  of  Miihl- 
hausen,  to  wit:  that  the  properties  of  cod-liver  oil  reside  neither  exclu- 
sively in  its  iodine,  nor  in  its  phosphorus,  nor  its  fatty  matter,  nor  its  ex- 
tractive matter,  but  that  it  is  the  entire  oil  with  all  its  principles  that 
cures;  and  we  cannot  say  that  any  vegetable  oil,  iodized  or  phos- 
phorized,  prepared  in  the  laboratory,  can  ever  wholly  replace  cod-liver  oil. 

We  shall  presently  return  to  this  question. 

Chronic  rheumatisin. — Though  most  of  those  who  have  examined  the 
therapeutic  action  of  cod-liver  oil  agree  as  to  its  utility  in  rachitis,  scrofula, 
and  even  pulmonary  phthisis,  they  are  by  no  means  so  unanimous  upon 
its  value  in  chronic  rheumatism.  It  is  certain  that,  in  France  especially, 
the  general  view  is  against  its  possessing  any  great  value  in  this  case. 
But  the  facts  reported  by  Schenck  (1.  c.)  are  really  interesting.  Perhaps  the 
cases  he  reports  are  rather  diseases  of  the  medulla  and  the  spinal  column 
than  true  rheumatism.  Yet  it  is  curious  to  see  paraplegia  of  years'  dura- 
tion, and  simple  or  double  sciaticas,  probably  due  to  an  affection  of  the  end 
of  the  spinal  cord,  yield  rapidly  to  the  influence  of  cod-liver  oil  after 
the  most  active  treatment  had  failed.  Let  us  recall  that  Wesener 
{HitfelamVs  Journal,  May,  1824),  Wolkmann  (ibid.  Nov.,  1834),  Schiitte 


166  THERAPEUTICS. 

(Arch.  f.  Medizln,  1824),  Eeder  (1.  c.)  report  many  cases  which  attest 
the  usefulness  of  this  medicine  in  chronic  or  scrofulous  diseases  of  the 
bony  system,  and  in  rheumatismal  affections. 

In  a  very  large  number  of  cases,  the  rheumatic  pains,  or  what  were 
called  such,  were  aggravated  by  the  first  doses,  and  this  circumstance 
must  probably  have  prejudiced  the  remedy  in  the  minds  of  experimenters 
or  physicians. 

A  great  uncertainty  still  prevails,  if  not  a  total  disagreement,  relative 
to  the  therapeutic  value  of  cod-liver  oil  in  chronic  rheumatism.  Dr.  Mtiller 
of  Miihlhausen,  in  seeking  for  the  reason  why  the  remedy  is  so  slighted 
among  us,  while  in  Northern  Europe  its  use  is  so  popular  and  its  success 
so  unquestionable,  has  established  a  distinction  which  accounts  for  this 
singular  difference  in  results  and  reputation. 

According  to  Miiller,  cod-liver  oil,  far  from  being  proper  in  all  cases  of 
rheumatism,  is  only  applicable  to  two  quite  special  varieties,  viz.: 

1.  Musculo-fibrous  rheumatism,  belonging  to  extreme  poverty,  and 
caused  by  privation,  embarrassment,  absence  of  air  and  light,  a  constitution 
originally  weak  and  deteriorated,  the  scrofulous  diathesis,  and  inheritance. 
This  form,  beginning  with  simple  painfulness  of  the  limbs,  occupies  the 
back  as  far  as  the  neck,  and  stiffens  and  contracts  more  or  less  perma- 
nently the  muscles  of  the  limbs  and  trunk,  without  ever  assuming  an  in- 
flammatory character;  is  accompanied  by  oedema  only,  without  redness, 
and  sometimes  leads  to  paralysis. 

2.  Fibrous  rheumatism,  due  to  a  prolonged  stay  in  moist,  cold  places. 
This  variety,  beginning  with  the  articulations,  presents  at  first  some 
mobility,  and  is  almost  wholly  confined  to  the  fibrous  tissues;  its  slow 
and  usuall}'  apyretic  progress  alters  nutrition  by  degrees,  and  leads  to 
exhaustion  without  contracture  or  paralysis. 

Cod-liver  oil  succeeds  only  in  these  two  forms  of  rheumatism,  and  when 
used  with  great  perseverance.  The  action  must  be,  as  in  the  diseases  pre- 
viously studied,  purely  indirect;  not  attacking  the  rheumatic  diathesis  it- 
self, but  previously  modifying  the  impaired  constitution,  improving  the 
nutrition,  and,  in  a  word,  combating  the  cachectic  state  which  forms  the 
chief  obstacle  to  cure  {Bulletin  de  la  Soc,  ruhl.prutiipie^  1851-52). 

If  this  distinction  be  just,  wh}-  need  we  wonder  that  cod-liver  oil,  given 
under  precisel>'  opposite  conditions,  in  inflammatory  or  sub-inflammatory 
forms  of  rheumatism,  often  increases  the  pain  with  the  first  doses;  and 
that  many  practitioners,  discouraged  by  these  bad  results,  abandon  the 
remedy  absolutely  in  the  treatment  of  rheumatism  ? 

The  cachectic  conditio7i  in  general. — If,  as  we  have  tried  to  prove,  the 
cod-liver  oil  draws  almost  all  its  power,  even  in  the  best  determined  affec- 
tions, from  its  reconstructive  virtues,  if  it  is  at  orice  a  good  food  and  an 
excellent  tonic,  it  naturally  follows  that  it  must  render  excellent  ser- 
vice in  that  general  state  of  deterioration  which  we  call  the  cachectic 
state. 

Here  is  an  important  practical  question  which  we  find  clearly  stated  in 


ALTERATIVES.  167 

that  excellent  treatise  from  which  we  have  already  drawh,  and  from  which 
we  again  borrow: 

Whatever  cause  may  exist  for  the  cachectic  state — whether  it  be  due 
to  insufficient  or  bad  food,  absence  of  light  or  air,  the  prolonged  influence 
of  damp  cold,  want  of  exercise,  as  in  imprisonment  in  cells,  exhaustion 
produced  by  all  sorts  of  excess,  too  rapid  growth,  difficult  dentition,  abun- 
dant suppuration,  chronic  catarrh,  an  old  defect  in  the  digestion;  whether 
it  be  connected  with  a  special  morbid  diathesis,  the  syphilitic,  scorbutic, 
cancerous;  or  with  albuminuria,  diabetes,  etc. — experience  shows  that  in 
these  morbid  conditions,  so  diverse  in  cause  and  nature,  but  all  producing 
one  result,  deterioration  of  constitution,  languor,  perverted  or  insufficient 
nutrition,  cod-liver  oil  sometimes  produces  the  most  unexpected  and  per- 
manent cures  by  its  nutritive  and  stimulant  properties. 

After  all  we  have  said,  in  spite  of  the  incredible  abuse  to  which  the  oil 
is  daily  subjected,  we  fear  not  to  conclude  that  the  introduction  of  cod- 
liver  oil  into  therapeutics  is  one  of  the  happiest  conquests  of  our  age. 

Dr.  x\nstie  has  obtained  remarkable  cures  of  refractory  chorea,  paraly- 
sis agitans,  epilepsy  and  mercurial  tremor,  by  this  remedy  {British  Med. 
Journal,  March,  1803). 

Ilemeralopia. — Dr.  Desponts,  of  Fleurance  (Gers),  having  obtained 
marked  success  in  hemeralopia.  Professor  Gosselin  was  directed  to  make 
a  report  on  his  work  to  the  iVcademie  de  medecine,  and  became  convinced 
of  the  efficacy  of  the  treatment  in  an  epidemic  which  affected  several  sol- 
diers of  the  garrison  of  Paris.  When  left  to  itself  the  attack  lasted  two 
or  three  weeks.  Under  the  influence  of  the  oil  the  cure  was  much  more 
rapid,  and  the  soldiers  were  able  to  resume  day  and  night  service  after  three 
days  of  treatment.  M.  Gosselin  also  remarks  that  this  night-blindness  is 
preceded  by  a  sort  of  premonitory  blepharitis,  and  he  thinks  that  if  the 
latter  were  treated,  the  hemeralopia  would  not  make  its  appearance  (Aca- 
demic de  medecine,  15  juillet,  1862).  The  same  success  had  previously 
been  obtained  at  Lisbon;  and  subsequently  at  Hans,  by  Dr.  Surmay  {Bul- 
letin de  therapeutiqiie,  1862,  I.,  427). 


Substitutes  foe  Cod-liver  Oil. 

In  Belgium  and  Germany  a  few  physicians,  who  were  soon  followed 
by  a  large  number,  denied  to  this  oil  the  possession  of  special  properties, 
and  concluded  that  the  substance  known  in  commerce  as  fish-oil,  which 
is  chiefly  derived  from  the  cetacea,  possesses  the  same  properties  as  that 
which  is  drawn  from  the  liver  of  the  ray  or  cod.  Bretonneau,  especially, 
gave  credit  to  this  view;  this  physician,  whose  authority  in  therapeutics 
is  so  considerable,  prescribed  to  his  patients  indifferently  whale-oil  and 
cod-liver  oil;  we  have  often  heard  him  say  that  he  always  obtained  the 
same  success.  The  use  of  fish-oil  is  popular  in  the  most  northern  latitudes. 
The  races  of  Kamtchatka,  Lapland,  and  Spitzbergen  combat  the  depres- 


168  THERAPEUTICS. 

sion  which  the  absence  of  solar  light  produces,  by  drinking  enormous  quan- 
tities of  whale-oil.  All  along  the  coast  of  the  Baltic  and  the  North  Sea, 
whale-oil  and  cod-liver  oil  were  indifferently  given  by  the  people  to  weakly 
children  or  sickly  adults;  and,  as  we  have  said,  physicians,  struck  with  the 
results  of  this  empiricism,  repeated  the  experiments  and  confirmed  the  re- 
sults. 

Some  Belgian  physicians  have  gone  further.  One  of  these,  Dr.  Dubois, 
substitutes  poppy-seed  oil,  which  is  edible,  for  cod-liver  oil.  He  has  col- 
lected fourteen  cases  of  rachitis,  and  ten  of  various  strumous  diseases, 
which  were  submitted  by  him  to  the  action  of  poppy-oil;  and  in  several 
of  these  cases,  especially  those  of  rachitis  and  scrofulous  caries,  no  better 
results  could  have  been  gained  by  using  cod-liver  oil.  He  gives  it  to  chil- 
dren, at  first  in  the  dose  of  half  a  tablespoonful  or  a  tablespoonful  morning 
and  evening,  and  increases  the  dose  progressively  ("  Annales  de  la  Soc. 
de  m^d.  d'Anvers). 

Dr.  Pophen  recommends,  in  strumous  affections,  as  glandular  indura- 
tion, scrofulous  ulcers,  enlargement  of  bones  with  or  without  caries,  the 
use  of  bacon  lightly  fried.  He  gives  this  on  an  empty  stomach,  in  the  dose 
of  8  grammes  (  3  ii.);  directly  after  he  eats,  in  any  kind  of  soup,  the  drip- 
pings which  came  from  the  bacon  while  frying,  and  an  hour  later  he  takes 
a  cup  of  acorn-coffee  with  slices  of  buttered  bread. 

When  the  disease  is  slight,  from  four  to  six  weeks  of  this  treatment 
are  said  to  suffice  for  a  cure;  when  the  symptoms  are  very  severe,  the  med- 
ication should  be  continued  for  nearly  three  months. 

Well-smoked  raw  ham  and  good,  non-fermented  beer,  are  among  the 
very  best  auxiliaries  in  diet  (  Wochenschri/f  f.  d.  (jesammte  Ileilk.,  1841). 

When  at  the  head  of  a  large  hospital  for  children,  we  made  compara- 
tive trials  of  butter  eaten  on  bread  and  ordinary  cod-liver  oil.  When  the 
quantity  of  butter  eaten  was  large  (GO — 150  grammes,  §  ii. — v.  per  day), 
the  rachitic  children  rapidly  improved;  almost  as  fast  as  when  cod-liver 
oil  was  given.  Butter,  which  is  an  animal  oil  as  truly  as  the  oil  of  the 
cetaceans  and  fishes,  acted  analogously  to  the  latter. 

We  alwaj's  follow  this  method  for  persons  who  are  too  much  opposed 
to  the  use  of  cod-liver  oil.  In  order  to  sustain  the  confidence  of  the 
parents,  who  cannot  see  how  so  simple  an  element  as  butter  can  have 
virtue,  we  often  add  to  it  some  of  the  elements  of  cod-liver  oil.  Our  most 
usual  formula  is  the  following: 

Very  fresh  butter 300  grammes  (nearly  3  x.). 

Iodide  of  potassium. .  . .        0"05  centigrammes  (gr.  0'008). 

Phosphorus O'OOS  "  (gr.  0'00046). 

Bromide  of  potassium  ..        0*3  "  (gr.  0'046), 

Chloride  of  sodium  ....        1  gramme  (gr.  15). 
Misce  secundum  artem. 

This  quantity  is  to  be  used  in  three  days,  upon  bread.  The  phosphorus 
may  be  omitted  without  doing  much  harm. 


ALTERATIVES.  169 

In  England,  the  oil  is  sometimes  replaced  by  fresh  cream,  to  which  is 
added  salt,  sugar,  or  rum.  M.  Fonssagrives  has  used  it  with  success 
{Bullet,  de  thercqy.,  1861,  t.  LXI.). 

Bauer,  of  Tubingen,  has  used  in  several  diseases  different  classes  of 
oil,  as  that  of  olive,  poppy,  flaxseed,  and  fish;  these  have  been  applied 
only  to  the  outside,  by  friction  of  the  whole  surface  of  the  body,  using  a 
fine  sponge,  and  the  oil  being  previously  warmed  somewhat.  The  even- 
ing was  the  usual  time  for  the  friction ;  the  patient  was  then  wrapped  in 
a  woollen  covering  and  left  for  two  hours.  In  the  majority  of  the  cases, 
abundant  sweating  of  the  entire  surface  formed  the  first  phenomenon, 
and  in  children  it  was  often  accompanied  by  an  eruption  somewhat  re- 
sembling roseola. 

A  second  remarkable  effect  was  a  calm  of  the  nervous  system,  which 
soon  produced  a  quiet,  deep  sleep.  The  third  was  an  increase  of  all  the 
secretions,  an  easier  expectoration,  more  abundant  urine,  and  a  beneficial 
activity  of  the  liver.  The  latter  effect  was  quickly  observed  in  children; 
the  stools,  which  had  been  green  and  acid-smelling,  became  yellow  and 
normal  in  aspect. 

We  may  then  look  for  salutary  effects  from  oily  friction  in  all  such 
affections  as  nervous  pains,  convulsions,  rheumatism,  etc.,  where  the  above 
calming  effect  is  the  principal  one  desired. 

It  must  be  allowed  that  the  use  of  oil,  internally  or  externally,  pre- 
sents many  inconveniences.  If  put  into  the  stomach  we  have  to  fear  in- 
digestion or  disgust,  if  it  is  used  for  a  length  of  time;  and  its  use  by 
friction  is  uncleanly.  But  the  annoyances  attending  upon  its  external 
use  may  be  much  more  easily  borne  than  those  which  are  caused  by  con- 
tinued ingestion.  Dr.  Bauer's  experiments  were  all  made  with  frictions. 
He  cites  eight  observations  in  which  he  used  various  oils  for  very  distinct 
forms  of  scrofulous  disease,  especially  in  children.  The  results  were  en- 
tirely in  agreement  with  what  has  been  said  above.  In  cases  where  the 
disease  originated  in  the  retrocession  of  an  exanthema  or  the  disappear- 
ance of  a  strumous  malady,  frictions  with  oil  recalled  the  eruption,  even 
after  several  other  means  of  attaining  this  end  had  failed  {Hull,  de  la  soc. 
med.  de  Gand). 

Absenic. 

Therapeutic  Action. — Internal  use. 

Intermitteiit  fevers. — The  principal  chief  reputation  of  arsenic  was 
acquired  by  its  use  in  intermittent  fevers;  a  reputation,  however,  which 
has  been  much  contested.  This  use  was  not  known  in  Europe  until  the 
end  of  the  seventeenth  century  and  the  beginning  of  the  eighteenth. 
Gohl  speaks  of  a  Prussian  army  surgeon  who  gave  to  soldiers  that  had 
intermittent  fever,  small  doses  of  a  powder  containing  three  parts  of 
arsenic  and  one  of  nitre,  a  remedy  which,  according  to  the  testimony  of 


170  THEE  APEUTICS. 

Gohl,  which  will  not  be  questioned,  was  very  certain,  but  at  the  same 
time  very  injurious,  "certissimura  at  nequissimum "  {^Comment,  in  act. 
nied.  JBerolin.,  Dec.  4,  v.  iii.,  p.  6).  Lemery,  in  his  chemistry,  speaks  of 
its  frequent  employment  in  France  by  charlatans  and  army  surgeons  for 
intermittent  fevers.  The  testimony  of  Van  Helmont,  Zeller,  Wepfer, 
Stahl,  is  to  the  same  purport  (Harles:  loc.  cit.,  pp.  GO,  Gl,  62). 

The  first  grave  authority  that  wrote  upon  the  febrifuge  virtues  of 
arsenic  was  Hadrien  Slevogt,  Professor  at  Jena  ("De  exceptionibus,  sive 
permissione  prohibitorum,  et  prohibitione  permissorum,"  Jena,  1700);  and 
a  little  later,  the  remarkable  work  of  Melchior  Frick  (Friccius),  a  phvsi- 
cian  of  Ulm,  appeared. 

Slevogt,  having  used  arsenic  for  years  in  tertian  and  quartan  inter- 
mittents,  declared  it  the  supreme  febrifuge,  and  very  superior  to  cinchona. 
By  its  use  he  avoided  the  relapses  and  the  accidents  consecutive  upon 
intermittent  fever  and  the  use  of  cinchona.  He  gave  arsenic  on  the  days 
of  apyrexia,  and  even  on  the  day  of  fever  at  the  beginning  of  the  access, 
in  the  dose  of  from  2  to  7  centigrammes  (gr.  30 — 105)  according  to  the 
patient's  strength,  but  associated  theriac  with  it,  to  moderate  its  irritant 
properties.  Melchior  Frick,  by  the  facts  which  he  published,  gave  arsenic 
a  much  greater  importance  as  a  febrifuge.  He  commonly  used  orpiment, 
which  he  mixed  with  rock-crystal  and  camphor,  making  a  powder.  Tliis 
powder  he  affirmed  to  be  superior  to  cinchona,  and  he  never  saw  a  patient 
that  was  not  cured  by  it.  His  success  was  such  as  to  give  rise  to  the  fol- 
lowing language:  "  Experientia  nos  docebit,  arsenicum  in  febribus  inter- 
mittentibus  adhibitum  omnes  eas  dotes  possidere,  quibus  optima  remedia 
prredita  esse  debent  ("  Paradoxa  de  Yenenis,"  1710,  p.  30  et  seq.). 

To  this  testimony  we  may  add  that  of  Keil,  Bernhardt,  J.-C.  Gmelin, 
Don  Monro,  Jacobi,  Huermann  (v.  Harles,  1.  c,  p.  QQ  et  seq.);  but  the  two 
Plencitz',  towards  the  end  of  the  last  century,  established  the  reputation 
of  arsenic  as  a  febrifuge.  ("Acta  et  observ.  med.,"  Prag.  et  Vienna', 
1783,  cap.  iii.).  These  two  physicians  gave  arsenic  at  the  Vienna  orphan 
asylum,  to  an  immense  number  of  patients  with  tertian  and  quartan  fever. 
They  never  saw  bad  effects,  and  the  remedy  seemed  to  them  surer  and 
quicker  than  any  they  had  previously  used.  They  employed  arsenious 
acid  in  the  enormous  dose  of  2 — 5  centigrammes  (gr.  0*3 — 0'8).  The 
remedy  was  used  with  almost  constant  success  in  thousands  of  cases  of  in- 
termittent fever.  "  Ejusque  usu  in  millenis  fere  febrium  intermittentium 
casibus  raro  frustratos  fuisse  affirmant."  Harles  is  rightly  surprised  that 
such  marked  success  did  not  establish  the  use  of  arsenic  in  Austria  and 
Hungary,  but  explains  it  by  Stoerck's  opposition  to  arsenic,  an  opposi- 
tion the  more  powerful  from  the  fact  that  he  held  a  leading  rank  at 
court  and  in  the  schools. 

While  arsenic,  as  recommended  by  the  Plencitz',  failed  to  make  head 
against  the  envious  hostility  of  Stoerck,  it  was  becoming  popularized  in 
England  by  Thomas  Fowler  ("  Medical  Reports  on  the  Effects  of  Arsenic 
in  the  Cure  of  Agues,  Remittent  Fevers,  and  Periodic  Headach,"  1786). 


ALTEKATIVES.  iTl 

Among  240  cases  of  intermittent  fever,  171  were  perfectly  cured  by  arsen- 
ic, 45  resisted  it  and  were  treated  successfully  by  cinchona,  and  24,  who 
did  not  strictly  observe  the  rules  of  treatment,  were  not  cured.  Arnold 
cites  24  cases  of  success  in  tertian  and  quartan  fevers,  and  very  rarely 
had  relapses.  Freir,  of  Birmingham,  claims  to  have  cured  more  than  a 
thousand  workmen  without  ill  consequences  by  Fowler's  method. 

At  the  same  time  as  the  latter,  Robert  Willan  and  Richard  Pearson 
contributed  much  to  the  adoption  of  arsenical  preparations  among  the 
physicians  of  Great  Britain  in  intermittent  fevers.  Willan's  testimony 
is  very  strong:  "I  know  of  no  remedy  more  sure,  more  efficient  and  easier 
to  take,  in  the  treatment  of  intermittent  fevers,  than  this  (Fowler's)  arse- 
nical solution."  Pearson,  who  modified  the  solution  a  little,  and  gave 
his  own  name  to  it,  as  Fowler  had  given  his  to  that  which  he  had  invented, 
bestowed  upon  it  his  full  confidence,  which  the  public  shared  when  a  prince 
of  the  blood,  the  Duke  of  York,  was  cured  by  arsenic  of  an  intermittent 
fever,  which  had  previously  resisted  cinchona. 

These  numerous  examples  and  publications  gave  to  arsenic  a  reputa- 
tion which  had  begun  to  spread  in  France  and  America,  when  the  wars 
waged  by  Great  Britain  against  the  United  States  and  our  Revolution 
broke  off  all  her  sciencific  relations,  and  some  of  our  physicians,  Valen- 
tin, Desgranges,  Fodere,  Dufour  of  Montargis,  Bouillier  of  Pont-Saint- 
Maxence;  in  Italy,  Brera,  and  in  Germany,  Harles,  preserved  the  tradi- 
tions of  Slevogt,  Frick,  the  Plencitz',  Fowler,  and  Pearson.  Harles,  in 
particular,  in  his  important  monograph  on  arsenic,  placed  before  the  medi- 
cal public  all  previously  published  experience,  reported  his  own  results,  and 
contributed  more  than  any  one  to  spread  the  use  of  arsenic.  But,  in 
spite  of  new  facts,  again  collected  in  France  by  M.  Gendrin,  the  invasion 
of  physiological  medicine,  so  noxious  to  therapeutics,  opposed  the  intro- 
duction of  arsenic  into  French  practice,  and  at  that  period  there  were  per- 
haps not  twenty  physicians  in  the  country  Avho  dared  to  use  a  remedy, 
which  was  universal  among  our  neighbors  beyond  sea. 

M.  Boudin,  however,  a  former  physician  in  chief  at  the  Hopital  mili- 
taire  du  Roule,  at  Paris,  after  numerous  trials  upon  himself,  brought  arse- 
nic into  honor  among  us.*  He  introduced  precise  rules  for  adminis- 
tration, previously  unknown,  and  demonstrated  a  law  of  tolerance,  the 
knowledge  of  which  seems  to  us  to  assist  greatly  in  the  handling  of  arsen- 
ical preparations.  The  number  of  intermittent  fevers  which  have  been 
treated  by  this  physician  in  the  hospitals  of  Marseilles,  Versailles  and 
Paris,  equals  the  enormous  sum  of  more  than  four  thousand ;  and  such  seems 
to  be  the  perfection  of  the  method,  that  he  states  that  he  has  not  once  had 
to  resort  to  sulphate  of  quinia  since  the  end  of  1843;  a  result  very  differ- 
ent from  that  of  Fowler,  who  cured  only  171  out  of  240  cases  of  fever. 

Boudin's  rules  are  the  following: 

*  Boudin  :  "  Traite  des  fievres  intermitt.  et  contag.  des  contrees  palud.,"  followed 
by  "Eecherches  sur  Temploi  therap.  des  prepar.  arsenicales,"  Paris,  1842. 


172  THERAPEUTICS. 

First  ride. — Commence  with  an  emetic  (Ipecac,  1  gramme  (  gr.l5) ; 
tartar  emetic,  1  decigramme  (gr,  1'5)  ),  if  the  fever  is  associated  with  gastric 
embarrassment,  suppression  or  diminution  of  appetite.  When  the  fever 
has  been  broken,  return  to  the  emetic,  if  the  appetite  is  at  all  backward, 
in  order  to  give  full  opportunity  for  a  substantial  and  abundant  diet. 

Second  rule. — Give  arsenious  acid  in  divided  doses,  the  last  portion 
being  administered  at  least  two  hours  before  the  exjoected  attack;  make 
the  dose  proportional  to  the  character  of  the  fever,  which  varies  accord- 
ing to  place,  season,  and  individuality. 

Take  advantage  of  the  tolerance  at  the  onset  to  raise  the  dose  of  ar- 
senious acid  as  high  as  possible,  giving  every  quarter  of  an  hour  1  milli- 
gramme, or  only  -^  milligramme — 1  gramme  or  |-  gramme  of  the  solution 
(=gr.  0*008 — O'Olo;  gr.  8 — 15).  As  the  tolerance  lessens,  diminish  the 
dose  by  degrees,  and  insist  on  subdivision;  and  if  there  is  opportunity, 
give  a  part  or  the  whole  by  the  rectum.  By  the  latter  method,  5,  10  cen- 
tigrammes, and  even  more,  are  borne,  when  the  stomach  has  ceased  to 
bear  one  centigramme  (=gr.  0'8 — 1*5 — O'lo).  Give  the  remedy  on  the 
days  of  intermission  as  on  those  of  access. 

Continue  for  a  time  proportionate  to  the  duration  of  the  disease  and 
its  previous  obstinacy  under  treatment.  In  first  attacks,  continue  it  at 
least  a  week  after  the  accesses  have  wholly  ceased.  In  old  obstinate 
cases,  continue  for  thirty,  forty,  fifty  days,  and,  if  necessary,  longer. 

Third  ride. — Let  the  diet  be  substantial,  as  abundant  as  possible,  and 
limited  only  by  the  appetite  and  the  power  to  digest.  Let  it  consist  by 
preference  of  roast  beef  or  mutton;  let  generous  wine  be  drank,  in  pro- 
portion to  the  deterioration  which  the  patient's  constitution  has  suffered; 
let  watery  drinks  be  abstained  from  as  far  as  possible. 

To  sum  up:  emetics,  to  relieve  gastric  oppression,  and  suppression 
or  diminution  of  appetite  at  the  beginning,  or  persistent.  Dose  of  arse- 
nious acid  proportioned  to  tolerance,  subdivided,  and  continued  without 
interruption  for  a  time  proportioned  to  the  duration  and  obstinacy  of  the 
fever.  Administration  by  the  mouth  or  the  rectum,  according  to  circum- 
stances. In  a  word,  oppose  a  sort  of  arsenical  diathesis  to  the  paludal 
diathesis.  Nourish  abundantly;  sweep  the  patient  along;  grade  the  three 
parts  of  treatment  in  such  a  way  as  to  make  the  time  most  profitable  to 
the  patient.  Such  are  the  rules  followed  by  M.  Boudin,  the  strict  observ- 
ance of  which  he  recommends  to  those  who  wish  to  derive  the  most  advan- 
tage possible  from  febrifuge  treatment. 

This  treatment  does  not  consist  in  a  simple  substitution  of  arsenic  for 
cinchona,  but  in  a  complex  medication,  in  which  arsenic  is  seconded  by 
two  powerful  agents,  emetics  and  good  feeding.  The  evacuants  relieve 
gastric  embarrassment  and  hasten  the  return  of  appetite,  the  regimen 
shortens  convalescence,  combats  the  tendency  to  relapses,  and  prevents 
the  manifold  consecutive  troubles  which  seem  connected  with  poverty  of 
the  blood. 

Tolerance. — Many  patients,  says    Boudin,   bear  5  centigrammes  (gr. 


ALTERATIVES.  173 

0*77)  of  arsenious  acid  perfectly  well  at  the  beginning,  but  cease  to  tolerate 
it  after  two  or  three  days,  when  the  fever  is  broken.  The  intolerance 
appears  in  nausea,  headache,  loss  of  appetite;  in  a  higher  degree,  it  causes 
vomiting  and  diarrhoea.  The  physician  should  be  careful  to  follow  the 
oscillations  of  tolerance,  and  to  adapt  his  doses  to  them;  diminishing  the 
dose  as  toleration  lessens,  insisting  on  subdivision,  and  administering  per 
rectum  if  necessary.  One  who  has  ceased  to  bear  1  centigramme  (gr. 
0*15)  by  the  mouth  will  often  bear  5,  10,  or  even  20  by  the  rectum.  M. 
Boudin,  when  sick,  tolerated  10  centigrammes  (gr.  I'o)  of  arsenious  acid 
by  the  mouth;  but,  when  in  health,  he  has  experienced  abundant  saliva- 
tion and  slight  nausea,  after  taking  only  2  centigrammes  (gr,  0*o).  But 
this  rule  is  subject  to  exceptions. 

Dose. — This  is  not  fixed,  but  must  be  adapted  to  the  special  genius 
of  the  fever  and  the  patient's  tolerance.  It  is  as  undesirable  to  give  too 
little  as  too  much.  By  neglecting  this  rule,  temporary  inconvenience  has 
been  caused,  or  a  part  of  the  effect  has  been  missed.  M.  Boudin  has  often 
had  success  with  one  milligramme  (gr.  O'Olo).  In  other  cases  he  has  had  to 
raise  the  dose  to  5  centigrammes  (gr.  0'77)  and  more  in  the  24  hours. 

Action  on  the  spleen. — M.  Boudin's  experience  has  perfectly  demon- 
strated the  disappearance  of  splenic  engorgement,  under  the  influence  of 
arsenical  treatment. 

Melapses. — The  small  proportion  of  relapses  indicates  the  same  fact. 
The  relative  infrequency  of  relapses  may  depend  on  the  disappearance  of 
splenic  engorgement,  or  the  intermittent  fever  may  be  independent  of 
the  engorgement;  in  the  latter  case  we  need  not  give  attention  to  it. 

M.  Maillot's  experiments  at  Lille  gave  15  relapses  out  of  42  cases 
treated  by  sulphate  of  quinia  in  a  period  of  five  months,  or  84  relapses  to 
100  fevers  in  a  year, 

M,  Masselot  {Arch.  ghi.  de  niecL,  1846),  among  311  intermittents 
treated  at  Versailles  by  Boudin  in  32  months,  counts  but  10  relapses,  or 
1'2  per  hundred  in  a  year.  The  numerical  results  seem  thus  far  to  be  in 
favor,  if  not  of  arsenic,  at  least  of  M.  Boudin's  manner  of  using  it. 

Prophylactic  achninistration  hi  marshy  regions. — Boudin,  arguing 
from  the  extreme  rarity  of  relapses  after  arsenical  treatment,  and  the 
rarity  of  fevers  which  Dr.  Stokes  has  noted  in  a  marshy  district  of  Corn- 
wall, has  proposed  the  use  of  very  small  doses,  say  1  milligramme  (gr. 
0"015)  of  the  acid  per  day  as  a  preventive.  The  harmlessness  of  this  prac- 
tice has  been  proved;  its  efficacy  remains  to  be  determined. 

M.  Boudin's  success  has  been  confirmed  by  that  of  a  great  number  of 
practitioners,  which  the  medical  press  has  recorded.  We  will  only  recall 
the  essays  of  MM.  Neret  at  Nancy,  Tessier  at  Lyons,  Maillot  at  Lille, 
Bernier  at  Sarreguemines,  Leterme  at  Luynes,  Maziere  at  Ile-Boin,  Vaul- 
pre  and  Travail  in  the  marshes  of  La  Bresse,  Yerignon  at  Hy^res,  Por- 
tafax  in  Corsica,  Garbiglietti  at  Turin,  Rouis  in  Algiers,  Sigaud  in  Brazil, 
of  Conet,  first  medical  officer  of  the  navy  at  Guadeloupe,  and  the  re- 
cent successes  of  Dr.  Sistach,  M.  Millet  of  Tours,  and  Fremy  of  Paris. 


17-1  THERAPEUTICS. 

Finally,  Groldschinidt,  physician  to  the  penal  colony  of  Ostwald,  at  the 
request  of  Hirtz,  has  experimented  upon  the  comparative  value  of  sul- 
phate of  quinia  and  arsenic,  arriving  at  nearly  the  same  results  as  those 
of  Boudin. 

jVeuralgias. — The  watery  solution  and  the  powder  of  arsenious  acid 
have  been  used  by  M.  Boudin  on  a  large  scale  in  neuralgia.  He  states 
that  he  has  been  constantly  successful  when  the  disease  was  of  a  pro- 
nounced periodic  type;   much  less  so  when  this  was  not  the  case. 

In  rebellious  neuralgias,  especially  those  which  return  periodically, 
cinchona  or  sulphate  of  quinia  must  be  given  in  such  large  doses  as  often 
to  injure  the  digestion  or  the  nervous  system.  The  disease  often  reap- 
pears in  spite  of  the  cinchona,  and  then  this  remedy  is  inadequate.  These 
are  cases  in  which  arsenical  preparations  render  services  which  no  other 
remedy  could  supply. 

The  title  of  Fowler's  paper  sufficiently  shows  that  he  had  found  ar- 
senic useful  in  periodic  neuralgia;  he  reports  seven  cases  of  cure.  Hoff- 
mann gives  the  following  (Harles:  1.  c,  p.  331):  a  man  of  49  years  had 
had  for  a  certain  time  a  periodic  headache  which  returned  at  seven  every 
morning  and  lasted  till  one  in  the  afternoon ;  the  pain  was  so  great  as  to 
cause  furious  delirium.  Opium,  valerian,  ammonia  and  other  remedies 
had  been  used  in  vain.  At  last  the  arsenical  elixir  was  used,  with  infu- 
sion of  valerian  and  of  sweet  flag,  when  the  complaint  disappeared  in  one 
day.  In  the  lievue  niedlcale  fran^alse,  mai,  1828,  we  read  the  history  of 
a  nervous  headache  which  had  lasted  for  years  and  was  cured  with  ar- 
senic by  Dr.  Alexander.  Cahen,  physician  to  the  hospice  Rothschild, 
has  treated  65  neuralgias  with  arsenic,  with  almost  constant  success 
{^ArcJi.  de  med.,  1863). 

Chronic  rheumatism,  esj^eciaUy  arthritis  nodosa. — H.  Gu^neau  de 
Mussy  has  proposed  arsenical  baths  as  an  effective  remedy  in  nodose 
rheumatism.  He  distinguishes  two  categories;  in  one,  the  process  is 
frankly  chronic;  in  the  other,  the  disease  is  more  recent,  the  reaction  lies 
in  the  background,  the  nervous  excitability  very  prominent;  or  else  the 
disease,  though  very  old,  belongs  to  that  class  of  chronic  affections 
which  seem  composed  of  a  long  series  of  crises  more  or  less  acute — chronic 
in  the  obstinate  persistence  of  the  process,  and  acute  in  the  manifesta- 
tion. In  the  former  case,  when  the  chronic  condition  is  unequivocal,  he 
uses  the  following  mixture  for  a  full  bath : 

Subcarbonate  of  sodium 100  grammes  (gr.  1543). 

Arseniate  of  sodium 1  gramme   (gr,  15). 

He  raises  the  dose  of  arseniate  rapidly  to  2  grammes,  which  he  rarely 
exceeds. 

In  the  second  case,  if  there  is  reason  to  fear  excitement,  he  uses  ar- 
seniate of  sodium  alone,  in  the  dose  of  1 — 3  grammes  (gr.  15 — 45)  in  a 
simple  or  gelatinous  bath. 

At  the  outset  he  gives  a  bath  every  other  day;  later,  one  every  day, 


ALTEEATIVES.  175 

with  occasionally  a  day  for  rest.  The  duration  of  treatment  depends  on 
the  effects  produced.  One  of  M.  Gueneau  de  Mussy's  patients  had  as 
many  as  sixty  baths. 

Concurrently  with  the  baths,  he  used  to  give  decoction  of  guaiac,  and 
a  mixture  containing  from  GO  centigrammes  to  1  gramme  of  extract  of 
cinchona  (gr.  9 — 15),  and  from  30  centigr.  to  1  gramme  of  iodide  of  potas- 
sium. To  anticipate  a  natural  objection  to  this  complex  treatment,  he 
remarks  that  this  mixture,  employed  alone  for  fifteen  years,  had  given 
no  result.  The  author  has  further  tried  this  treatment  successfully  in  all 
the  forms  of  chronic  rheumatism,  in  various  neuralgias,  in  a  case  of  rheu- 
matismal  paraplegia  and  certain  chronic  affections  of  the  skin  (I^ulletm 
de  therapeutique,  1860). 

Herpetlsrn. — Dartres. — The  French  pathologists  have  long  used  the 
word  dartre,  without  a  very  exact  meaning;  it  merely  designated  rebel- 
lious cutaneous  affections  with  a  tendency  to  become  generalized.  The 
tendency  of  to-day  is  to  associate  eruptions  with  diseases  of  which  they 
are  symptoms.  Hence  Lalouette's  descriptions  of  scrofulous  eruptions 
or  scrofulidae,  Biett's  of  syphilidfe,  Franck's  of  arthritidjB,  Rayer's  of 
artificial  affections;  to  which  Bazin  has  added  a  chapter  on  parasitic  dis- 
eases. But  some  remain  unclassed;  there  is  a  series  of  cutaneous  mani- 
festations which  possess  in  the  highest  degree  this  refractory  character 
and  this  tendency  to  relapse  and  to  generalization.  Have  these  a  common 
link,  and  do  they  belong  to  a  general  malady  ?  M.  Bazin  believes  this 
to  be  the  case;  and  he  gives  to  them  the  name  of  herpetidas. 

According  to  him,  dartres  are  cutaneous  affections,  non-contagious, 
obstinate  in  relapsing,  and  originating  not  in  one  single  vice,  the  dartrous 
diathesis,  as  Hardy  thinks,  but  in  three,  scrofula,  arthritis  and  herpetism. 
Bazin  admits  that  there  are  herpetic  nervous  and  visceral  affections,  as 
there  are  internal  scrofulous  manifestations;  among  the  chief  of  which 
are  dyspepsia,  asthma,  dysmenorrhoea  and  certain  neuroses,  nervous  ere- 
thism being  the  leading  symptom  of  all  the  herpetic  affections. 

Why  have  M.  Bazin's  opinions  not  had  more  adherents  ?  It  is  because 
this  disease  or  class  of  diseases  includes  affections  as  numerous  as  varied, 
more  difficult  to  classify  than  the  scrofulous,  syphilitic,  gouty  or  rheu- 
matic; they  are  not  merely  hereditary  diseases,  but  are  par  excellence  fam- 
ily and  race  diseases,  and  lose  their  character  as  they  are  transmitted. 
But,  remarkably  enough,  these  affections,  which  become  degraded  more 
and  more  in  the  process  of  transmission,  may  at  last  break  out  in  a  frankly 
herpetic  form;  a  real  alternate  generation,  as  it  would  seem.  If  it  were 
not  so,  there  could  happen  but  one  of  two  things:  either  the  hereditary 
disease  would  continue  to  reproduce  itself  with  the  same  character,  or  it 
would  disappear  completely.  (See,  for  further  details,  Pidoux:  Introduc- 
tion to  a  New  Doctrine  of  Pulmonary  Phthisis,  Union  iiiediccde,  avril  et 
mai,  18G5). 

The  apparent  result  of  a  great  number  of  modern  researches  is,  that 
arsenic  is  good  for  all  these  affections. 


176  THEKAPEUTICS. 

The  herpetic  eruptions  form  three  groups:  1,  the  pseudo-exanthema- 
tous  herpetides,  superficial  and  rapid  in  their  course,  behaving  in  general 
like  accidental  acute  maladies,  and  not  directly  requiring  arsenical  treat- 
ment; 2,  the  circumscribed  herpetidte;  3,  the  generalized  or  inveterate 
herpetidie.  Arsenical  medication  is  suited  to  the  two  last  groups,  which 
include  pityriasis,  psoriasis,  prurigo,  lichen,  furuncle,  eczema,  and  pem- 
phigus. 

Various  ?iervous  affections. — Epilepsy. — The  monograph  of  Harles 
reports  four  cases  of  epilepsy  cured  by  arsenic  (p.  324).  One  was  ob- 
served by  Edward  Alexander,  an  Englishman;  the  second  by  Duncan  of 
Edinburgh;  a  third  by  Hoffmann,  and  a  fourth  by  the  author.  The  two 
latter  cases  seem  esj^ecially  satisfactory;  but  what  are  we  to  infer  from 
two  cases,  especially  cases  of  epilepsy  ?  The  same  author  quotes  cases 
of  the  cure  of  St.  Vitus'  dance  by  arsenic. 

Nervous  state. — The  so-called  nervous  temperament,  when  developed 
into  a  pathological  form,  becomes  nervous  erethism,  and  may  exist  in- 
dependently and  alone,  or  be  attached  to  ordinary  diseases,  stamping  ac- 
cidental or  other  affections  with  its  constitutional  or  hereditary  vice.  It 
easily  engenders  hypochondria,  hysteria,  neuralgia  and  the  visceral  neu- 
ropathies. This  state  is  beneficially  affected  by  arsenic,  as  has  been 
proved  by  an  excellent  paper  by  M.  Isnard  of  Marseilles  {^De  Varseiiic 
dans  la  pathologic  du  systenw  nerveux,  Paris,  1865).  AVhile  stupefiants, 
sedatives,  antispasmodics,  etc.,  have  to  be  employed  for  the  disturbances 
of  sensation  and  motion,  iron  and  cinchona  for  the  atony  and  anaemia, 
and  a  crowd  of  other  remedies  according  to  s3'mptoms,  arsenic  may  take 
the  place  of  all  of  them,  deserving  (according  to  M,  Isnard)  to  be  the 
medicine  of  the  nervous  state,  and  (according  to  Bazin)to  be  the  specific 
remedy  of  herpetism. 

Isnard  considers  it  one  of  the  best  tonics  in  convalescence  from 
acute  diseases.  Given  to  pregnant  women  with  nervous  erethism,  it  is  of 
great  use,  especially  at  the  beginning  of  pregnancy,  and  may  be  preferred 
to  opium  and  belladonna,  or  at  least  may  be  placed  by  their  side.  He 
has  succeeded  in  supporting  with  it  the  strength  of  women  who  were 
overtaxed  with  nursing. 

Cerehrcd  co)igestion  and  apoplexy. — Dr.  Lamare-Picquot,  of  Honfleur, 
has  i^roposed  arsenious  acid  as  a  preventive  of  apoplexy.  We  do  not 
vouch  for  its  efficacy,  which  has  only  been  tested  by  the  author  upon  his 
own  person,  and  in  the  case  of  twenty-three  patients  whom  he  says  he 
cured  by  this  remedy.  The  observations  of  M.  Cahen  "  Arch,  de  med.," 
18G3,  in  which  congestion  connected  with  neuralgia  was  relieved  by  ar- 
senic may,  like  those  of  Isnard,  support  those  of  M.  Lamare-Picquot. 

Angina  pectoris. — This  is  one  of  the  most  atrocious  of  diseases.  We 
have  given  temporary  relief  by  stramonium,  but  the  attacks  returned 
with  a  ferocity  which  destroyed  hope.  If  the  case  given  by  M.  Alexan- 
der is  true  (as  we  may  not  doubt),  arsenic  rendered  immense  services  to 
him  in  such  a  case.     The  patient  was  a  man  of  fifty-seven,  affected  with 


ALTER  ATm:s.  l77 

angina  pectoris  of  the  severest  kind.  He  took  six  drops  of  Fowler's  so- 
lution three  times  a  day,  and  had  no  fresh  attack.  But  as  slight  symp- 
toms of  the  access  were  observed,  Alexander  resumed  the  remedy,  and 
the  cure  remained  complete  (Harles:  1.  c,  p.  329.  M.  Garin,  of  Lyons, 
likewise  cured  a  periodic  neuralgia  of  the  heart.  If  there  be  a  question 
between  an  organic  and  a  nervous  affection  of  the  heart,  arsenic  may  ren- 
der valuable  help  in  diagnosis. 

M.  Tessier,  of  Lyons,  has  published  in  the  Journal  de  medecine  de 
Lyon  (mai,  1848)  two  interesting  observations  upon  the  use  of  arsenical 
preparations  in  extremely  severe  neuroses.  The  first  case  was  one  of  in- 
termittent neurosis  of  the  heart  and  the  organs  of  respiration,  in  a  man 
aged  sixty-six;  the  other  was  a  gastralgia  with  atrocious  pain  in  a  woman 
of  thirty -three.     The  first  case  was  cured,  the  second  only  improved. 

Asthma. — The  reader  will  remember  accounts  of  the  poison-eaters, 
and  especially,  the  custom  existing  among  certain  mountaineers,  of  swal- 
lowing- a  little  arsenic  to  give  themselves  wind  and  endurance  in  climb- 
ing,  or,  as  they  say,  to  make  them  "  volatile,"  when  they  are  setting  out 
for  a  journey  in  the  mountains.  The  drivers  in  these  countries  follow  a 
similar  practice  with  their  horses,  mingling  arsenic  with  the  oats  when 
they  have  a  severe  climb  to  perform. 

Led  by  these  hints.  Dr.  Koepl  made  a  trial  of  the  virtues  of  arsenic  in 
certain  functional  troubles  of  respiration.  He  gave  Fowler's  solution  to 
several  persons  affected  with  asthma,  and  states  that  they  derived  marked 
benefit  from  it. 

At  the  beginning  of  this  article  we  gave  the  opinions  of  the  ancients, 
beginning  with  Dioscorides,  who  praised  arsenical  drugs  used  for  fumiga- 
tions or  taken  internally,  in  the  treatment  of  chronic  troubles  of  the  chest 
or  larynx.  When  our  first  edition  was  published  we  had  never  tried 
these  medicines,  nor  even  seen  arsenic  prescribed  in  thoracic  diseases; 
but  we  must  say  that  our  reading  of  the  authors  who  have  paid  attention 
to  arsenic  had  convinced  us  that  it  was  evidently  useful  in  intermittent 
fevers,  and  equally  so  in  chronic  catarrh  and  spasmodic  asthma.  The  tes- 
timony was  too  full  to  permit  us  to  doubt  this;  but  to-day  we  can  speak 
from  personal  experience. 

"It  is  given  internally,"  says  Dioscorides,  "to  patients  who  have  pus 
in  the  chest.  Mixed  with  honey,  it  makes  the  voice  clearer,  and  it  is 
given  to  asthmatics  in  draughts  with  resin.  In  inveterate  coughs,  the 
patient  is  made  to  breathe  through  a  pipe  the  vapor  of  a  mixture  of  resin 
and  arsenic." 

It  is  needless  to  quote  again  from  Pliny,  Galen,  and  his  Arabic  com- 
mentators, who  seem  to  have  all  copied  Dioscorides,  and  have  perhaps 
adopted  the  master's  dicta  without  having  tried  for  themselves;  but,  at  a 
more  recent  date,  attentive  observers  have  shown  by  experiment  the 
truth  of  the  statements  of  Dioscorides  and  his  followers. 

At  the  close  of  the  sixteenth  century,  George  Weith  invented  an  elec- 
tuary containing  orpiment,  which  he  gave  in  considerable  doses  in  the 
12 


178  THERAPEUTICS. 

severest  cases  of  asthma  (Jo.  Languis:  " Epistol.  med.,"  Hanov.,  1605,  p. 
847).  It  appears  from  this  author  that  the  use  of  arsenical  fumigation  in 
asthma  was  in  a  way  popular  in  certain  climates  of  northern  Europe. 
Ettmiiller  gave  asthtnatic  patients  a  mixture  of  tobacco  and  arsenic  to 
smoke,  and  by  degrees  increased  the  dose  of  the  latter  to  the  enormous 
quantity  of  75  centigrammes  (gr.  13)  without  the  slightest  accident 
(Harles:  1.  c,  p.  328). 

Dr.  Koepl  was  one  of  the  first  to  follow  these  indications,  and  to  try 
Fowler's  solution  in  certain  cases  of  asthma;  an  experiment  which  met 
with  the  hoped-for  success  in  quite  a  large  number  of  cases.  His  experi- 
ence has  been  repeated  by  others;  and  as  regards  ourselves,  we  have  used 
arsenical  preparations  internally  for  several  years,  and  have  found  that 
they  rendered  real  service.  We  most  commonly  prescribe  arsenite  of 
sodium  in  the  following  draught: 

Arsenite  of  sodium 0*05  (gr.  0'77). 

Distilled  water 100        (gr.  1540). 

Tincture  of  cochineal  to  color q.s. 

The  patient  takes  a  teaspoonful  of  the  above  at  the  beginning  of  each  of 
the  two  principal  meals — a  precaution  which  may  assist  in  enabling  cer- 
tain delicate  stomachs  to  tolerate  it.  This  dose  represents  about  2^  mil- 
ligrammes (gr.  0"038)  of  the  arseniate  of  soda. 

We  also  order  the  inhalation  by  arsenical  cigarettes.  For  this  pur- 
pose a  solution  is  prepared,  containing  from  1  to  4  grammes  (gr.  15 — 
CO)  of  arsenite  of  sodium  in  20  grammes  of  distilled  water.  A  leaf  of 
papier  Joseph  is  soaked  in  this  solution,  dried,  divided,  and  formed  in  the 
shape  of  a  cigarette;  thus  each  one  contains  a  known  weight  of  the  salt, 
from  5  to  20  centigrammes  (gr.  0"77 — 3*0).  The  patient  lights  the  cigar- 
ette, fills  his  mouth  with  smoke,  and  then  by  a  slow  inspiration  draws  it 
into  the  bronchi.  At  first,  four  or  five  mouthfuls  are  breathed  twice  or 
three  times  a  day;  and  as  the  patient  becomes  accustomed  to  it  the  num- 
ber is  increased.  When  there  is  great  oppression,  leaves  of  datura  stra- 
monium should  be  included  in  the  cigarette. 

In  this  simple  process  the  arsenical  salt  is  reduced  by  contact  with  the 
carbon  in  the  incandescent  paper,  forming  carbonate  of  soda,  oxide  of 
carbon,  and  volatile  arsenic,  which  is  carried  by  the  smoke  into  direct 
contact  with  the  pulmonary  mucous  membrane. 

According  to  M.  Viaud-Grand-Marais  these  inhalations  are  most  suc- 
cessful in  that  which  Laennec  called  asthma  with  puerile  respiration,  and 
in  emphysema.  M.  See  (1.  c.)  reports  similar  success;  also  an  observation 
by  Dr.  Julius,  who  quickly  relieved  a  lady  who  had  been  asthmatic 
twenty-five  years. 

Chorea. — We  owe  to  M.  Gelle,  a  former  interne  of  Gillette's  at  the 
Children's  Hospital,  an  excellent  th^se  (1860)  upon  the  use  of  arsenic  in 
in  chorea,  from  which  we  borrow  most  of  the  following  details. 


ALTERATIVES.  179 

In  the  Gazette  medicate  of  1840,  p.  139,  it  is  stated  that  Dr.  Leesse  of 
New  York  gave  Fowler's  tincture  in  the  dose  of  six  or  eight  drops  morn- 
ing and  evening  to  patients  from  eight  to  ten  years  old.  M.  Rayer  ob- 
tained good  results  likewise  ( Union  medicate,  1847).  In  England  the 
remedy  has  often  been  used  with  success  by  Martin,  Gregory,  Latter,  and 
more  recently  by  Babington,  Hughes,  and  Begbie.  Romberg  saw  a  cure 
effected  in  two  months  under  the  influence  of  this  treatment;  M.  Dieu- 
donne  has  seen  the  movements  disappear  in  twelve  days.  M.  Barthez  no- 
ticed distinct  improvement  on  the  second  day  in  one  case,  and  in  an'other 
case  a  cure  on  the  eighth  day.  In  an  observation  of  Aran's,  a  young  girl 
resumed  the  use  of  her  needle  on  the  eighth  day.  Guersant  pere  first  ob- 
served improvement  on  the  second  day.  Among  Gillette's  cases,  col- 
lected by  Gelle,  there  were  several  which  felt  the  influence  in  36  or  48 
hours;  but  in  general  the  action  was  manifest  from  the  fifth  day,  and 
more  so  on  the  eighth,  with  a  distinct  improvement  in  the  patient's  condi- 
tion. 

M.  Gelle  has  also  sought  to  define  the  indications  and  the  contraindica- 
tions for  arsenical  treatment  in  chorea.  It  appeared  to  him  that  it  failed  in 
nervous  and  sanguine  patients,  who  were  improved  by  emetics  and  opium. 
Arsenic,  on  the  contrary,  succeeded  admirably  in  patients  suffering  from 
privation,  lymphatism,  chlorosis,  and  cachexia.  This  opinion  is  that  of 
Romberg  and  Bourguignon.  Much  more  than  this:  in  three  severe  cases, 
in  which  the  incessant  movement  wore  out  the  clothes  and  the  skin, 
deglutition  was  impossible,  the  sphincters  relaxed,  etc.,  arsenic  was  also 
useful,  producing  a  rapid  improvement,  and  a  cure  in  twenty  days. 

M.  Letenneur,  of  Nantes,  cured  four  choreic  patients  in  a  very  short 
time  by  giving  twice  a  day  a  teaspoonf  ul  of  a  solution  containing  y^Vo"  ^^ 
arsenious  acid,  or  one  centigramme  per  diem  (gr.  0'15)  {Journat  de  mede- 
cine  de  V  Quest,  nov.,  1867). 

Chlorosis. — Dysmenorrhoea. — Nothing  is  more  common  than  for  the 
daughters  of  dartrous  persons  to  have  difficult  menstruation,  accompanied 
by  hysteralgia  and  the  phenomena  Avhich  it  produces  by  reflex  action.  In 
a  higher  degree  there  is  amenorrhoea,  with  the  same  symptoms  and  con- 
secutive anaemia.  The  first  thing  given  is  usually  iron,  which  succeeds 
the  first  time,  but  a  year  or  eighteen  months  later  the  d3'smenorrhoea  re- 
appears, iron  is  given  again,  but,  to  the  surprise  of  all,  it  increases  the 
symptoms  instead  of  relieving  them;  if  arsenic  is  then  used,  a  success  is 
obtained  which  is  sufficiently  explained  by  the  subsequent  development 
of  the  patient's  health,  or  rather,  her  pathology.  We  employ  in  such 
cases  arsenious  acid  in  preference  to  arseniate  of  iron,  which  is  less  suc- 
cessful. 

Phthisis. — Are  we  to  believe  that  Beddoes  (quoted  by  Girdlestone) 
treated  successfully  a  phthisical  man,  two  of  whose  brothers  had  died  of 
mesenteric  consumption ;  that  Bernhardt  (''  Chymische  Versuche,"  p.  233,) 
cured  a  number  of  children  of  mesenteric  tabes  by  giving  them  three  times 
a  day  a  small  dose  of  an  arsenical  preparation;  and  that  Ferriar  ("Med. 


180  THERAPEUTICS. 

Facts  and  Observ.")  gave  Fowler's  solution  with  advantage  at  all  stages 
of  whooping-cough  ? 

In  1841,  having  made  trials  upon  phthisical  patients  and  those  affected 
with  chronic  catarrh  of  the  larynx,  we  said  that  we  had  obtained  in 
phthisical  cases  not  cures,  but  a  suspension  of  the  symptoms,  which  is 
very  extraordinary  in  a  disease  whose  fatal  progress  is  arrested  by  noth- 
ing. We  have  seen  the  diarrhoea  moderate,  the  hectic  diminish,  the  cough 
become  less  frequent,  the  expectoration  assume  a  better  character — but 
we  have  not  cured.  New  tubercles  formed  and  softened,  and  death  fol- 
lowed; it  was  postponed,  it  is  true,  but  it  was  inevitable.  Yet  our  re- 
sults have  served  to  encourage  us,  and  nothing  prevents  our  hoping  that, 
in  cases  of  limited  extent,  we  may  obtain  a  complete  cure. 

Since  this  time  we  have  given  arsenic  in  phthisis  on  a  ver^'^  large  scale, 
and  with  the  following  results:  In  the  first  place,  when  arsenic  acts  well 
in  phthisis,  it  does  so  promptly.  What  distinguishes  it  essentially  from 
the  water  of  Eaux  Bonnes  is  that  its  action  requires  no  period  of  incuba- 
tion. We  have  never  seen  it  produce  either  those  immediate  aggravations 
which  are  sometimes  prolonged  for  several  months  after  a  season  at  the 
baths,  and  which  are  followed  by  such  a  remission  in  the  symptoms  as 
never  occurred  before  the  remedy  was  taken;  or  the  critical  and  salutary 
appearance  of  a  cutaneous  affection,  of  neuropathic  symptoms,  of  piles, 
gravel,  arthritic  or  herpetic  symptoms  several  months  after  the  minero- 
thermal  impregnation,  at  a  time  when,  none  of  the  remedy  having  been 
taken  in  the  interval,  its  effect  might  have  been  supposed  to  be  negative. 
The  action  of  arsenic  is  immediate  or  nothing.  It  somewhat  resembles 
that  of  a  food,  which  acts  at  once,  lasts  for  a  short  time,  and  requires  to 
be  renewed. 

Whenever  we  have  seen  arsenic  produce  good  effects  in  phthisis,  it  has 
been  immediately,  without  appreciable  pathogenetic  phenomena,  with- 
out a  period  of  incubation,  without  ulterior  critical  or  salutary  manifes- 
tations. Here,  as  in  the  case  of  quinia,  the  symptoms  are  immediately 
suppressed. 

When  arsenic  excites  the  appetite  and  restores  hnematosis  by  its  rapid 
stomachic  action,  these  good  effects,  promptly  obtained  and  purchased  by 
no  disturbance  or  risk,  are  apt  to  lead  astray.  At  the  first  glance  (which 
is  too  often  the  last)  one  may  suppose  oneself  in  possession  of  the  ideal 
remedy;  but  all  these  effects  are  specious  rather  than  profound. 

To  obtain  the  restorative  and  sedative  effects  of  arsenic  in  phthisis,  it 
is  well  to  remember  that  the  remedy  does  not  act  at  all  when  the  patient 
does  not  eat,  unless  it  produces  its  stomachic  or  excitant  effects  upon  the 
appetite;  it  does  not  save  waste,  except  by  increasing  the  receipts  of  the 
system.  Like  cod-liver  oil,  arsenic,  in  order  to  develop  its  effects,  re- 
quires exercise,  and,  up  to  a  certain  point,  all  the  acts  of  ordinary  life;  it 
therefore  is  much  less  useful  to  consumptive  patients  in  a  hospital  than  in 
civil  life. 

In  certain  irritable  persons  it  produces  a  sort  of  tension  and  conges- 


ALTERATIVES.  181 

tion  of  the  brain  which  somewhat  resemble  intoxication;  they  say  that  ii 
"goes  to  their  head."  This  property  gives  arsenic  a  resemblance  to  the 
agents  which  fix  nutrition,  such  as  coffee,  tea,  and  coca.  When  this  phys- 
iological action  is  kept  within  bounds,  it  is  not  inconsistent  with  the 
therapeutic  effects  we  have  named.  But  it  has  another  and  not  a  very 
rare  immediate  effect,  which  absolutely  contraindicates  its  use.  This  is 
a  certain  spasm,  apparently  localized  at  the  two  orifices  of  the  stomach, 
which  paralyzes  or  obliterates  the  functions  of  that  viscus.  Several  pa- 
tients have  mentioned  to  us  this  effect,  accompanied  by  praecordial  anxiety 
and  a  very  painful  and  suffocating  sense  of  arrested  digestion.  If  this 
effect  be  not  excessive,  it  still  forms  an  absolute  contraindication  to  the 
use  of  the  remedy.  It  is  not  so  with  the  slight  colics,  accompanied  with 
diarrhoea,  which  arsenic  sometimes  causes. 

Arsenic,  then,  seems  to  be  an  arrestive  agent,  aconservant.  Like  cin- 
chona, it  fixes  the  action  of  the  vascular  extremities  and  prevents  their 
yielding  to  morbid  or  debilitating  impressions.  This  is  perhaps  equiva- 
lent to  saying  that  arsenic  does  not  aid  nutrition  (Pidoux:  "  Tlierapeutique 
comparee  de  la  phthisic,"  1873).  M.  Moutard  Martin  has  tried  the  remedy 
on  a  large  scale,  and  reaches  nearly  the  same  conclusions  as  ours  {Bulletin 
de  tlierapeutique,  1868).  He  admits  a  very  positive  action  of  arsenic 
upon  phthisis,  especially  when  the  disease  has  made  little  progress,  is 
slow  in  its  course,  and  attended  with  little  fever. 

In  advanced  phthisis  with  hectic  fever  arsenic  has  less  marked  effects; 
but  they  exist,  and  sometimes  alleviate  the  disease — an  effect  for  which 
we  may  well  be  thankful. 

M.  Moutard  Martin  very  justly  observes  that  success  would  be  more 
frequent  if  patients  were  more  persevering.  Too  often  they  mistake  im- 
provement for  cure,  abandon  the  hygienic  measures  and  the  treatment — 
and  repent  speedily. 

CJtronio  disorders  of  the  digestive  tract. — At  the  beginning  of  this 
article  we  stated  that  the  Styrian  peasants  took  arsenic  as  a  stomachic. 
Dr.  Koepel  has  recorded  a  curious  fact  in  his  communication  upon  poison- 
eaters  (1.  c.),  which  deserves  a  place  here. 

A  servant  in  a  chateau  wished  to  rid  himself  of  a  too  strict  housekeeper. 
For  this  purpose  he  added  very  small  doses  of  arsenic  to  the  lady's  food 
for  a  long  time,  hoping  that  the  chronic  nature  of  the  symptoms  would 
shield  him  from  suspicion.  To  his  great  surprise,  the  lady  continued  for 
months  to  improve  in  plumpness,  complexion,  and  spirits.  Seeing  that 
small  doses  produced  effects  contrary  to  his  wish,  he  added  a  much  larger 
one  to  a  fricasseed  chicken;  but  the  severity  of  the  symptoms  which  fol- 
lowed soon  raised  suspicion  against  him,  and  he  was  delivered  up  to  jus- 
tice. 

Some  cattle-breeders,  in  order  to  fatten  their  oxen,  calves  and  swine 
quickly,  mix  a  little  arsenic  with  their  food,  and  succeed  in  giving  them 
a  good  appearance  in  a  very  short  time. 

M.  Tessier,  of  Lyons,  whose  observations  on  the  use  of  arsenic  in  cer- 


182  THERAPEUTICS. 

tain  neuroses  of  the  respiratory  and  digestive  organs  we  have  quoted,  makes 
the  important  remark  that  in  his  experience  he  had  found  that  arsenic  stim- 
ulated the  appetite  and  aided  digestion,  while  diminishing  the  excessive  sus- 
ceptibility of  the  stomach.  He  further  says  that  the  remedy  seems  to  him 
to  have  a  favorable  influence  in  certain  chronic  affections  of  the  digestive 
tube,  and  especially  in  gastralgia.  M.  Legroux  has  benefited  a  case  of 
diabetes  by  using  arsenic  and  hydrotherapeutics. 

These  various  facts,  taken  from  physiology  and  pathology,  joined  to 
some  analogous  observations  of  our  own,  seem  to  us  to  justify  the  use  of 
very  small  doses  of  arsenic  in  certain  refractory  diseases  of  the  digestive 
organs,  as  dyspepsia,  or  gastro-enteralgia  accompanied  by  rebellious  diar- 
rhoea, and  certain  cases  of  lientery  in  cachectic  persons,  where  nothing 
else  is  of  use. 

It  is  demonstrated  that  several  mineral  springs,  including  those  of  Mont- 
Dore,  Bourbonne,  la  Bourboule,  Vichy,  Plombieres,  and  especially  Bussang, 
contain  a  dose  of  arsenic  which  is  appreciable  by  analysis.  Who  knows 
but  this  dose  of  arsenic,  jjitherto  neglected,  may  have  some  part  to  play 
in  certain  cures  of  chronic  diseases  of  the  digestive  passages,  all  the  honor 
of  which  is  attributed  to  the  alkaline  salts  ? 

Leared,  a  physician  at  the  Great  Northern  Hospital  in  London,  pub- 
lished in  the  British  Medical  Journal,  Nov.  23  and  30,  1867,  two  articles, 
in  which  he  reports  good  success  from  the  use  of  an  arsenical  solution 
(probably  Fowler's)  in  gastralgia.  Leared  carefully  defines  the  nature  of 
his  cases,  saying  that  the  pains  of  the  stomach  were  very  intense,  occuri'ing 
when  the  organ  was  empty  as  well  as  when  full,  and  often  producing  nau- 
sea, sometimes  vomiting.  This  pain  is  accompanied  by  a  sense  of  constric- 
tion, from  which  it  often  gets  the  name  of  cramp  or  colic  of  the  stomach, 
and  by  its  intensity  causes  a  feeling  of  faintness  and  collapse.  He  con- 
siders arsenic  wholly  contraindicated  when  the  pain  is  provoked  by  the  in- 
gestion of  food,  when  there  is  pyrosis,  and,  of  course,  in  cancer  or  ulcer  of 
the  stomach  {Bulletm  de  th'erapeiitique,  1859,  L,  p.  49). 

Diabetes. — We  have  sometimes  given  arsenic  in  diabetes,  and  the  re- 
sults have  seemed  to  us  not  unfavorable.  M.  Devergie  has  observed  the 
same  improvement  in  several  patients  of  his  ("  Traite  des  maladies  de  la 
peau,"  18G2,  p.  355). 

MM.  Legroux  Foville  pereet  fils,  and  Dr.  Titon,  of  Chalons-sur-Marne, 
have  obtained  similar  results  {Bidletin  de  tJierapeiitiqi(e,  1870,  I.,  p.  541). 
We  must  add  an  observation  by  Owen  Rees  [Lancet,  1854,  vol.  H.,  p. 
436).  But  there  have  also  been  reverses  M.  Brouardel  ("  Etude  critique 
des  di verses  medications  employees  contre  le  diabete  sucre:  These  d'agre- 
gation,"  1869,  p.  63)  recalls  that  Berndt  was  not  very  successful,  and  that 
two  trials  made  by  Lailler  and  Siredey  only  increased  the  glycosuria.  These 
differences  are  doubtless  owing  to  our  very  imperfect  knowledge  of  the 
varieties  of  glycosuria.  We  may  be  able  some  day  to  define  the  indica- 
tions exactly,  and  to  distinguish  the  cases  in  which  they  will  be  useful. 

Pellagra. — This  disease  often  baffles  our  therapeutics;  and  it  cannot 


ALTERATIVES.  183 

be  out  of  place  to  mention  six  cures  obtained  by  Dr.  Marenghi.  Arsenious 
acid  given  in  the  dose  of  2  milligrammes  per  day  (gr.  O'Oo)  brought  back 
the  appetite,  then  the  strength,  and  the  patients  recovered,  after  a  treat- 
ment of  two  or  three  months  ( Gaz.  med.  ital.  LomharcUa,  October  IG, 
1869;  and  Bulletin  de  th'erapeutique^  1870,  I.,  p.  40). 

Muscular  atrophy. — We  shall  make  the  same  statement  in  regard  to 
progressive  muscular  atrophy,  and  mention  a  remarkable  case  of  cure  by 
Dr.  Da  Silva  Lima  (of  Bahia),  in  the  Union  medicale,  nov.  30,  1869. 

Oxyuris  vermlcularis. — We  know  not  whether  the  experience  of  Coelius 
Aurelianus,  who  advised  arsenical  injections  for  the  destruction  of  intes- 
tinal worms,  has  been  repeated.  It  is  sufficient  to  know  the  parts  inhab- 
ited by  worms,  in  order  to  understand  that  injections  can  only  be  of  use 
■when  there  are  pin-worms;  and  in  this  case,  rectal  injections  with  an  arsen- 
ical solution  cannot  be  too  highly  praised.  While  we  were  in  service  at 
a  children's  hospital,  we  had  frequent  occasion  to  use  them.  For  an  in- 
jection of  200  grammes  (  3  viss.)  from  1  to  5  centigrammes  or  arseniate  of 
sodium  or  potassium  (gr.  O'lo — 0"77)  are  dissolved  in  water.  The  dose 
would  be  enormous  if  retained,  but  the  irritation  it  causes  is  so  great 
that  it  is  rapidly  ejected,  but  not  before  the  worms  are  destroyed. 

A  single  injection  is  usually  enough,  but  it  is  best  to  repeat  it  two  or 
three  days  in  succession,  and,  after  an  interval  of  four  days,  to  repeat  it 
two  or  three  days  more,  in  order  to  destroy  the  eggs  and  prevent  all  chance 
of  relapse.  We  have  never  given  arsenic  internally  for  worms;  it  is  prob- 
able, if  not  certain,  that  any  safe  dose  would  be  absorbed  by  the  stomach 
or  duodenum  before  reaching  the  large  intestine,  which  is  the  constant 
habitat  of  lumbrici  and  taenia?.  Perhaps  realgar  and  orpiment,  which  are 
slowly  soluble,  might  reach  the  large  intestine  without  being  wholly  de- 
composed, and  might  act  topically  there,  as  arsenical  injections  do  upon 
pin-worms.  But,  arsenic  used  in  this  way  would  be  a  dangerous  weapon; 
and  we  advise  physicians  never  to  use  it  except  in  the  case  we  have  indi- 
cated. 

Boudin  gives  arsenious  acid  in  injections  as  a  vermicide.  Beginning 
with  5  centigrammes  (gr.  0'77)  he  increases  it  gradually  to  10,  15,  and  20 
centigrammes  (gr.  1-5 — 2"27 — 3).  He  has  treated  taenia  thus,  giving  ar- 
senic at  the  same  time  by  the  mouth,  in  powder  with  white  sugar,  carry- 
ing the  (divided)  dose  to  7  centigrammes  per  day.  The  patient  passed 
large  pieces  of  tienia,  and  all  the  symptoms  ceased:  but  the  case  is  recent, 
and  he  hesitates  to  declare  the  cure  ■final. 

External  use  of  arsejiic. — Dioscorides  was  well  aware  of  the  escharotic 
properties  of  arsenic:  "Vim  habet  escharoticani  cum  ustione  et  cum  mor- 
sione  violenta  "  (Dioscor.) ;  "  Valet  perrodere  "  (Pliny).  Celsus,  Galen,  and 
many  others  knew  of  this  property:  "Arsenic  omnes  species  sunt  combu- 
rentes  "  (Rhazes) ;  "  Omnes  species  Arsenici  escharoticte  sunt  "  (Avicenna). 
We  shall  presently  see  with  what  success  the  moderns  have  used  prepara- 
tions of  arsenic  in  the  topical  treatment  of  cancerous  ulcers.  Theodore 
("Chirurg.,"  lib.  iv.,  p.  Ill)  used  these  properties  for  the  destruction  of 


184  THERAPEUTICS. 

fungous  vegetations  on  scrofulous  ulcers,  obtaining  an  easy  and  regular 
cicatrization. 

The  present  topical  use  of  arsenic  in  very  small  doses  produces  a  homoeo- 
pathic, that  is,  a  substitutive  action,  which  is  of  great  use  in  hastening 
the  cure  of  chronic  ulcers,  phagedaenic  dartres,  and  most  chronic  affections 
of  the  skin.  The  remedy  was  universally  adopted  in  the  treatment  of  cu- 
taneous disorders  down  to  the  time  when  mercury  took  the  supreme  posi- 
tion which  it  so  deserves.  Arsenic,  as  a  local  remedy  in  ill-conditioned 
ulcers,  is  sometimes  more  useful  than  mercury,  but  it  needs  to  be  handled 
with  extreme  care  and  in  minimal  doses.  A  physician  of  Paris,  who,  to 
his  diso"race,  makes  a  secret  of  the  i-emedies  he  uses  for  cancer  of  the  womb, 
produces  a  beneficial  change  in  the  amount  and  the  odor  of  the  discharge, 
and  evidently  prolongs  the  patient's  life,  by  lightly  touching  the  neck  of 
the  womb  with  cotton  impregnated  with  arsenical  oil.  Tiie  oil  must  be 
left  but  an  instant  in  contact  with  the  part,  and  the  amount  of  arsenic 
must  be  very  small  (5  parts  in  400,  for  example),  as  stronger  doses 
give  rise  to  inflammatory  accidents  which  it  is  not  always  easy  to 
arrest. 

In  small  doses,  these  preparations  may  cause  a  very  violent  inflamma- 
tion, and  in  a  larger  dose  they  destroy  the  life  of  the  parts  they  touch. 
These  have  therefore  been  used  for  the  double  purpose  of  producing  local 
modifications,  either  by  exciting  inflammation  of  another  character,  or  by 
destroying  the  superficial  diseased  tissue,  while  in  the  deeper  parts  arsenic 
produces  the  alterative  effects  of  which  we  spoke  above. 

When  a  local  inflannnation  on  the  surface  of  an  ulcer  or  wound  is  to 
be  produced,  very  small  doses  must  be  used,  5  centigrammes  (gr.  O*??) 
of  arsenious  acid  or  arseniate  of  sodium,  to  8  grammes  (  3  ii-)  of  cerate,  or 
twice  as  much  of  the  sulphide.  To  produce  superficial  eschars,  the  doses 
will  have  to  be  much  larger. 

The  most  celebrated  arsenical  powders  used  for  this  purpose  are  those 
of  Justamond,  of  Friar  Cosmo,  and  of  Plunket,  that  of  Rousselot,  which 
is  almost  the  only  one  used,  and  is  almost  the  same  as  Cosmo's,  and  that 
of  Dubois,  which  differs  little  from  Cosmo's  and  Rousselot's. 

These  powders  have  been  chiefly  used  in  treating  superficial  cancers 
of  the  skin;  they  are  made  into  a  paste  with  saliva  or  gum- water,  or  sim- 
ple water  or  a  little  white  of  egg,  and  are  spread  on  the  diseased  surface. 
Certain  precautions  are  important. 

Some  surgeons  used  to  excise  the  cancerous  surface,  to  remove  all  the 
indurated  nodules  with  the  bistoury,  and  to  cover  the  wound  directly  with 
arsenical  paste.  This  practice  was  followed  in  several  cases  by  severe 
toxic  symptoms  which  threw  great  discredit  upon  the  paste.  But  Du- 
bois, remarking  that  the  absorption  was  rapid  in  proportion  as  the  cut 
surface  was  recent,  but  was  almost  null  when  suppuration  was  well  estab- 
lished, laid  it  down  as  a  rule  to  excise  the  cancerous  surface  first,  and  not 
to  apply  the  paste  until  four  days  after.  Although  by  this  means  the  ab- 
sorption is  generally  avoided,  nevertheless,  when  the  surface  is  very  eX' 


\ 


ALTERATIVES.  185 

tensive,  the  poison  often  causes  death.  Hence  the  precept,  to  cover  the 
surface  piecemeal,  and  make  but  one  application  a  day. 

The  first  effect  of  the  arsenical  paste  is  a  very  violent  pain,  and  an 
erysipelato-phlegmonous  inflammation  of  great  extent,  lasting  usually  from 
four  to  eight  days.  The  escliar,  of  a  thickness  proportioned  to  that  of 
the  layer  of  paste,  separates  slowly,  and  usually  does  not  fall  until  from 
the  fifteenth  to  the  thirtieth  day;  cicatrization  is  usually  nearly  complete, 
and  the  skin  without  tubercles.  If  any  suspicious  vegetations  remain, 
they  must  be  checked  wuth  Vienna  caustic  or  acid  nitrate  of  mercury. 

Dupuytren  thought  it  was  not  necessary  to  produce  an  eschar,  but 
that  an  arsenical  preparation  which  would  cause  a  violent  inflammation 
was  sufficient  to  cure  superficial  cancers  of  the  skin.  He  ordered  the 
following  powder:  Arsenious  acid,  5  or  6  parts;  calomel,  100  parts.  This 
he  made  into  a  paste  with  a  gummous  solution,  and  applied  it  to  the  dis- 
eased portions,  removing  it  in  two  or  three  days,  and  renewing  the  appli- 
cation five  or  six  times,  according  to  the  exigency  of  the  case. 

In  lupus,  in  rodent  dartres,  the  same  paste  is  incontestably  useful; 
other  preparations  of  arsenic  should  be  given  at  the  same  time,  as  we 
said  above. 

Diseases  of  the  eyes. — The  irritant  properties  of  arsenical  preparations 
led  the  ancients  to  use  it  in  collyria,  as  we  do  the  mercurials. 

Depilatories. — Arsenical  preparations  have,  from  all  antiquity,  entered 
into  the  composition  of  most  of  the  epilatory  powders  and  pomades;  and 
such  is  the  case  at  present.  It  is  singular  that  the  ancients,  Dioscorides, 
Pliny,  Galen,  etc.,  while  mentioning  this  property,  state  that  it  is  very 
useful  in  alopecia.  It  is  useful,  no  doubt,  in  alopecia  due  to  chronic  dis- 
ease of  the  scalp,  when  it  acts  as  it  does  in  most  of  the  cutaneous  affec- 
tions which  it  cures.  As  a  depilatory,  arsenic  acts  immediately,  and  is 
used  in  large  doses,  while  for  those  diseases  which  cause  alopecia  it  is 
given  in  minimal  doses,  so  as  to  cause  only  a  transient  irritation  of  the 
skin. 

Gold. 

Therapeutic  Action. 

Si/philis. — The  beneficial  action  of  gold  in  the  treatment  of  syphilis  is 
incontestable.  We  may  read  in  the  writings  of  those  who  have  treated 
this  point,  observations  which  prove  this  action.  M.  Legrand's  work, 
which  has,  unfortunately,  no  resume,  contains  quite  distinct  evidence  of 
this.  He  first  reports  cases  of  primary  syphilis  cured  by  the  administration 
of  gold,  most  of  which  were  severe  enough  to  remove  the  suspicion  that 
they  recovered  spontaneously.  According  to  him,  the  influence  of  gold 
becomes  much  more  evident  when  the  primary  symptoms  are  of  long 
standing;  that  is,  when  the  syphilis  is  inveterate.  In  this  case  expecta- 
tion only  makes  the  disease  worse.     These  primary  symptoms  included 


186  THERAPEUTICS. 

all  those  which  were  seated  on  the  genitals  or  in  the  neighborhood,  as 
chancres,  vegetations,  buboes,  rhagades,  fissures,  etc.  An  equally  nume- 
rous series  of  observations  prove  the  good  effect  of  gold  in  secondary 
and  constitutional  accidents,  such  as  ulcers  of  the  nasal  fossse,  pharynx 
and  larynx,  cutaneous  syphilidae,  exostoses,  necroses,  caries,  venereal 
phthisis. 

The  effect  on  blennorrhagia  seems  to  have  been  less  manifest. 

During  the  administration  of  gold,  in  constitutional  syphilis,  certain 
phenomena  are  often  noticed,  about  which  the  physician  should  be  in- 
formed, if  he  would  not  fall  into  a  grave  error  of  treatment.  Sometimes, 
under  the  influence  of  auric  preparations,  all  the  local  syphilitic  symptoms 
assume  an  aggravated  intensity,  and  even  new  ones  appear.  These  phe- 
nomena, far  from  calling  for  apprehension,  are  desirable,  for  the  disease 
retrogrades  rapidly  in  a  few  days  after  they  appear.  It  is,  then,  very 
important  that  the  physician  should  retain  confidence,  and  be  able  to  in- 
form and  reassure  his  patient. 

Among  the  advantages  claimed  for  gold  by  its  partisans,  in  primary 
or  secondary  syphilis,  it  may  be  stated  that  it  is  usually  not  necessary 
either  to  stimulate  the  excrescences  or  to  make  use  of  any  topical  appli- 
cation. But  advantage  is  sometimes  derived  by  dressing  bad  ulcers  with 
a  pomade  of  gold,  or  by  rubbing  syphilitic  engorgements  with  the  same 
pomade. 

Dietrich,  who  has  published  an  interesting  paper  upon  the  mercurial 
disease,  denies  to  gold  the  possession  of  any  antisyphilitic  virtue;  but  he 
regards  it  as  the  most  powerful  remedy  of  the  mercurial  cachexia,  and 
believes  that  its  success  in  constitutional  syphilis  is  almost  always  due 
to  the  fact  that  the  supposed  syphilis  is  only  the  expression  of  an  intoxi- 
cation caused  by  the  use  of  mercur}'^  {Jour,  des  connaiss.  m'ed.-chir., 
1840,  juillet).  The  opinion  of  Dietrich  seems  to  us  untenable,  and  to  be 
refuted  by  facts;  but  it  is  none  the  less  true,  that  gold,  in  secondary 
venereal  symptoms  which  have  resisted  mercury,  ought  to  occupy  an  im- 
portant rank,  along  with  iodide  of  potassium, 

Scrofida. — Recent  cases  published  by  Legrand  [Journ.  des  connaiss. 
med.-chir.,  t.  V.,  4®  annee),  bear  witness  in  favor  of  the  preparations  of 
gold  in  scrofula.  He  gives  gold  internally  to  modify  the  constitution  and 
combat  the  scrofulous  vice,  and  at  the  same  time  he  treats  topically,  by 
pomades  containing  gold,  ulcerations  which  may  be  located  on  the  neck 
or  elsewhere.  Lalouette,  in  the  middle  of  the  last  century,  had  praised 
in  the  treatment  of  scrofula  "  two  livers  of  solar  sulphur,  and  an  antimo- 
nial  soap  by  the  solar  way,"  compounds  into  which  gold  entered;  and  later, 
M.  Chrestien,  of  Montpellier,  in  his  enthusiasm  for  gold,  lauded  the  vir- 
tues of  his  favorite  remedy,  not  only  in  scrofula,  but  also  in  dartres, 
goitre,  scirrhus  of  the  womb,  and  even  tubercular  consumption. 

The  experiments  made  at  the  Children's  Hospital,  by  Baudelocque, 
and  at  the  Charite  by  Professor  Velpeau,  in  the  treatment  of  scrofula, 
have  only  shown  the  worthlessness  of  preparations  of  gold  in  this  affec- 


ALTERATIVES.  187 

tion.  It  must  be  admitted  that  the  treatment  of  scrofula  is  generally 
unsuccessful  in  our  hospitals,  as  we  have  ha^  occasion  to  observe  in  re- 
gard to  cod-liver  oil.  The  reason  of  this  is  plain.  It  is  admitted  by  good 
observers  that  most  of  the  remedies  which  possess  a  real  value  in  scrofula 
act  less  as  specifics  than  as  stimulant  tonics,  or  special  modifiers  of  the 
organic  apparatus  which  governs  the  digestion  and  nutrition.  It  follows 
that  these  remedies  cannot  display  their  powers  unless  they  are  aided  by 
pure  air,  good  food,  and  cleanliness;  in  a  word,  by  hygienic  conditions 
quite  different  from  those  usually  found  in  public  establishments. 

As  regards  scrofulous  disease  in  general,  gold  has  certainly  come 
short  of  the  high  promises  which  its  patron  made  in  its  name.  The  ex- 
aggeration of  an  enthusiast,  however,  ought  not  to  throw  complete  dis- 
credit upon  a  remedy  which  may  have  value.  It  would  be  unjust  to 
deny  that  in  a  certain  number  of  the  cases  reported  in  Legrand's  last 
memoire  on  the  treatment  of  scrofulous  diseases  of  the  bones  (1851),  a 
manifest  improvement  has  been  effected  by  the  preparations  of  gold 
in  bony  scrofula. 

Niel,  of  Marseilles,  has  observed  cases  of  scrofulous  ophthalmia,  en- 
gorgement of  glands,  white  swelling,  tinea,  goitre,  and  even  elephanti- 
asis, cured  by  rather  large  doses  of  gold. 

Next  to  syphilis,  in  which  it  has  an  incontestable  efficacy,  the  dartres 
are  perhaps  the  most  successful  field  for  the  action  of  gold.  Chrestien 
and  Lallemand,  of  Montpellier,  have  observed  its  good  effects  in  leprous 
diseases  {Sulletin  de  theraj).,  1837,  t.  VII.).  In  cutaneous  diseases,  gold 
is  chiefly  used  topically,  though  its  partisans  regard  it  as  useful  when 
taken  internally. 

Dr.  Goetzner  has  succeeded  in  cases  of  ascites,  dependent  on  chronic 
affections  of  the  liver,  in  patients  who  are  not  exhausted;  he  gave  enor- 
mous doses  of  muriate  of  gold,  from  1  to  5  centigrammes  (gr.  0'15 — 0*77) 
(Merat  et  Delens:  "Diet,  de  mat.  med.,"  t.  V.,  p.  85). 

Diseases  of  the  digestive  tract. — At  the  beginning  of  this  article  we 
spoke  of  the  property  of  re-establishing  the  functions  of  the  stomach 
which  the  preparations  of  gold  possess.  M.  liCgrand  published  a  very 
interesting  memoire  upon  this  point,  in  1849,  containing  several  accounts 
of  very  young  children  affected  with  diarrhoea,  vomiting,  and  dyspepsia, 
and  in  a  state  of  i^iarasmus  which  caused  serious  apprehensions  for  their 
lives.  In  these  cases  he  gave  gold  in  powder,  incorporated  in  honey, 
from  2|-  to  5  centigrammes  (gr.  0*38 — 0'77)  in  30  grammes  (nearly  3  i.)  of 
honey,  of  which  one  or  two  teaspoonfuls  are  taken  daily.  He  previously 
quiets  pains  in  the  belly,  if  there  are  any,  by  baths,  cataplasms,  and  emol- 
lient clysters.  He  continues  the  gold  till  the  health  is  established,  and 
does  not  fear  to  give  30,  40  and  50  centigrammes  in  the  course  of  treat- 
ment (gr.  4'5  to  7'5). 

Amenorrlicea. — Gold  produces  congestion  of  the  pelvic  blood-vessels, 
and  is  a  powerful  means  of  provoking  menstrual  or  hjemorrhoidal  flowing. 
In  this  point,  gold  resembles  iodine.     It  follows  that  in  pregnant  women, 


188  THERAPEUTICS. 

or  in  those  who,  at  the  critical  period  or  at  any  other  time,  are  subject  to 
hasmorrhages,  or  in  those  who  have  a  permanent  fluxion  of  the  uterus,  it 
may  be  inconvenient  to  give  preparations  of  gold,  while  they  will  be  of 
advantage  if  the  menses  are  too  abundant  or  absent. 

It  remains  to  speak  of  gold  as  a  topical  agent,  Legrand,  and  after- 
wards Recamier,  used  perchloride  of  gold  as  a  caustic  in  ulcerations  of 
the  neck  of  the  uterus.  For  washes  or  vaginal  injections,  the  perchloride 
of  gold  and  sodium  is  used  in  solution  in  distilled  water,  in  the  propor- 
tion of  5  parts  to  3,000,  G,000  or  12,000  parts  of  the  vehicle.  Ointments 
of  gold  are  of  use  to  cleanse  venereal  ulcers,  and  to  modify  scrofulous 
and  dartrous  ulcerations  and  the  various  herpetic  disorders. 


Platinum. 
Therapeutic  Action. 

Hoefer,  guided  by  the  chemical  analogy  between  gold  and  platinum, 
tried  the  latter  in  the  treatment  of  those  diseases  in  which  gold  and  mer- 
cury are  usually  most  successful,  that  is,  syphilis  and  chronic  rheumatism. 
We  shall  confine  ourselves  to  an  analysis  of  the  facts  which  he  reports. 
He  cured  several  chronic  blennorrhagias  by  the  internal  use  of  perchloride 
of  platinum  in  the  dose  of  25  milligrammes  dissolved  in  180  grammes  of 
distilled  water,  to  be  taken  during  one  day.  In  the  case  of  women  he 
also  touches  the  inflamed  surfaces  with  a  liniment  composed  of  2  grammes 
of  perchloride  of  platinum  and  60  grammes  of  olive  oil  (gr.  30  and  3  xv.). 

In  acute  bletniorrhagia  he  has  had  success  with  urethral  injections  of 
a  solution  of  2  grammes  (gr.  30)  of  double  chloride  of  platinum  and  so- 
dium in  250  grammes  (  3  viii.)  of  distilled  water. 

The  primary  chancre  has  been  treated  with  the  platinum  lotion  de- 
scribed above,  with  the  local  application  of  an  ointment  composed  of  2 
grammes  of  platinum  finely  subdivided,  incorporated  with  30  grammes 
(  3  viiss.)  of  lard. 

In  syphilitic  chancre  of  the  veil  of  the  palate  and  throat  he  has  suc- 
ceeded by  giving  every  day  pills  made  by  the  following  formula: 

Perchloride  of  platinum 0'6  grammes  (gr.  9). 

Extract  of  guaiac 4'0        "         (gr.  GO). 

Powdered  licorice q.  s.  to  make  20  pills. 

The  internal  use  of  chloride  of  platinum  seemed  to  him  of  great  use 
in  chronic  rheumatism. 

He  remarked  that  in  certain  patients  under  this  treatment,  there  was 
a  considerable  increase  in  the  secretion  of  urine,  and  sometimes  a  slight 
painless  salivation  without  swelling  of  the  gums  and  tongue.  These 
phenomena  gave  the  patients  no  discomfort.  In  respect  to  the  digestion, 
he  thinks  that  constipation  was  more  frequent  than  looseness. 


ALTERATIVES.  189 

During  the  treatment  it  is  undesirable  to  subject  the  patient  to  a  se- 
vere and  fatiguing  regimen.  He  must,  however,  during  the  early  inflam- 
matory symptoms,  avoid  too  solid  food  and  too  stimulating  drink. 

He  observed  none  of  the  ill  effects  with  which  mercury  is  charged, 
after  a  treatment  with  platinum. 

The  resume  is  as  follows: 

1.  The  chlorides  of  platinum  are  poisons:  the  perchloride  in  the  dose 
of  1  gramme  (15  gr.),  and  the  double  chloride  of  platinum  and  sodium  in 
that  of  2  grammes  (gr.  30). 

2.  The  above  salts  are  less  poisonous  than  the  salt  of  gold  and  corro- 
sive sublimate. 

3.  A  concentrated  solution  of  perchloride  of  platinum  produces  acute 
itching  of  the  skin,  followed  by  a  slight  cutaneous  eruption  at  the  spot 
where  the  application  was  made.  Taken  internally,  it-  first  irritates  the 
mucous  coat  of  the  stomach,  causes  headache,  reacts  on  the  nervous  cen- 
tre, and  in  this  way  exercises  a  peculiar  alterative  reaction  wpon  the 
fluids  of  the  system. 

4.  The  double  chloride  of  platinum  and  sodium  produces  no  local 
irritation  of  the  skin.  Taken  inwardly,  it  does  not  react  upon  the  ner- 
vous centre  so  sensibly  as  the  simple  perchloride.  It  more  particularly 
increases  the  urinary  secretion. 

5.  The  perchloride  is  very  effective  in  syphilis,  especially  in  the  old, 
inveterate,  constitutional  forms. 

6.  Double  chloride  of  platinum  and  sodium  is  more  suitable  for  recent 
(primary)  syphilitic  symptoms.  It  is  equally  valuable  in  rheumatic  com- 
plaints. 

7.  Platinum  must  be  classed  among  such  alteratives  as  gold,  iodine 
and  arsenic.  It  differs  from  mercury  by  producing  a  previous  excitement 
and  by  not  producing  any  of  those  bad  results  which  are  ascribed  to  mer- 
cury. The  salts  of  gold,  which  seem  to  be  poisonous  in  much  smaller 
doses  than  those  of  platinum,  are  efficacious  (according  to  authorities) 
only  in  certain  cases  of  constitutional  syphilis. 

8.  Platinum  is  preferable  to  mercury  or  gold  as  an  alterative. 

We  do  not,  of  course,  accept  all  these  conclusions  of  Hoefer's,  for  a 
wider  experience  is  necessary  in  order  to  confirm  them. 


Silver. 

Diarrhoea. — Crystallized  nitrate  of  silver  has  been  recommended  in 
several  diseases  internally.  Boerhaave  gave  it  ("  libell.  de  mat.  med.")  as 
a  drastic  purgative  in  dropsy;  in  this  case  2^  centigrammes  (gr.  0'38) 
"was  mixed  with  the  same  quantity  of  nitre  and  made  with  bread-crumb 
into  a  pill,  to  be  given  every  half-hour  until  the  patient  begins  to  be 
purged.  We  have  advised  this  in  acute  dysentery,  giving  at  the  same 
time   twice  a   day  an  injection  with  500   grammes   (  3  xvi.)   of  distilled 


190  THEE  APEUTICS. 

water  containing  in  solution  15 — 50  centigrammes  (gr.  2"3 — 7*7)  of  ni- 
trate of  silver. 

We  have  long  used  nitrate  of  silver  very  frequently  for  diseases  of  the 
dio-estive  organs.  In  protracted  diarrhoea  of  nursing  infants,  if  diet,  regi- 
men and  magnesia,  bismuth  and  powdered  oculi  cancrorum  do  not  arrest 
it,  we  do  not  hesitate  to  prescribe  nitrate  of  silver,  observing  the  follow- 
ing rules  : 

If  there  are  griping  pains,  and  glairy  secretions,  or  glairy  tinged 
with  blood,  and  tenesmus  also,  we  order  morning  and  evening  an  injection 
of  250  grammes  (  §  viii.)  of  distilled  water  and  5 — 10  centigrammes  (gr. 
0*7 — I'o)  of  nitrate  of  silver,  according  to  the  child's  age;  sometimes 
after  the  liquid  is  expelled  we  order  a  fresh  injection  of  lukewarm  water 
to  which  is  added  half  a  drop  or  a  drop  of  Sydenham's  laudanum.  These 
simple  means  rarely  fail  to  cure  with  rapidity  a  diarrhoea  which  seems  to 
be  connected  with  a  phlegmasic  condition  of  the  mucous  membrane  of  the 
colon. 

But  if  the  diarrhoea  is  accompanied  by  nausea,  if  the  stools  are  serous, 
green,  lienteric,  we  do  not  hesitate  to  give  nitrate  of  silver  by  the  mouth 
as  follows  : 

Nitrate  of  silver 0*01  grammes  (gr.  0*15). 

Distilled  water 25*00        "  (gr.  385). 

Simple  syrup 15-00        "  (gr.  231). 

Of  this  a  quarter,  a  half  or  the  whole  is  taken,  according  to  the  effect. 
We  give  our  assurance  that  this  remedy  is  perfectly  innocent,  and  that 
there  is  no  reason  at  all  to  dread  its  use  internally. 

For  chronic  diarrhoea  in  adults  we  give  nitrate  of  silver  in  pills  or 
potions,  in  the  dose  of  5  or  10  centigrammes  (gr.  0-77 — 1*5)  daily;  if  the 
diarrhoea  is  due  to  inflammation  of  the  large  intestine,  we  give  injections 
containing  20  or  30  centigrammes  (gr.  3 — 4-5)  of  the  salt. 

In  1840,  Hudson  published  in  the  Dublin  Journal  of  Medical  Science 
an  interesting  paper  on  the  internal  use  of  nitrate  of  silver  for  some  af- 
fections of  the  mucous  membranes.  Osborne  previously  used  it  in  gas- 
tritis with  acid  vomiting;  Langton  Parker  placed  it  by  the  side  of  bis- 
muth and  opium  as  a  sedative  of  the  sensitiveness  of  the  stomach;  Bigers 
and  Steinetz  recommended  it  in  dyspepsia.  Hudson  repeated  their  ex- 
periments, and  found  the  salt  efficacious  in  rebellious  gastralgia  which 
had  entirely  baffled  other  powerful  remedies. 

We  have  often  found  this  method  useful  in  refractory  gastralgia,  es- 
pecially in  neuropathic  women  with  multiple  flying  neuralgia.  In  this 
case  we  give  the  nitrate  in  the  dose  of  1 — 3  centigrammes  (gr.  0'15 — 
0-45)  in  pills,  taken  between  meals.  These  are  continued  five  or  six  days 
together;  after  a  certain  lapse  of  time  we  resume  them,  according  to  the 
result. 

As  a  vermifuge,  it  is  used  in  the  same  way  (Fodere:  "Med.  leg.,"  t. 
IV.,  p.  163). 


ALTERATIVES.  191 

Neuroses. — Its  effect  upon  the  nervous  system,  quite  independently  of 
its  irritant  effects,  cannot  be  questioned  without  doubting  the  veracity 
of  a  great  number  of  worthy  practitioners. 

Nitrate  of  silver  has  been  one  of  the  most  popular  remedies  for  epi- 
lepsy. Not  that  even  the  twentieth  part  of  those  treated  have  been 
cured,  but  that  more  are  cured  than  by  any  other  method  except  that 
by  bromide  of  potassium.  As  the  doses  have  to  be  considerable,  we  be- 
gin with  5  milligrammes  (gr.  0"08)  morning  and  evening,  and  increase 
gradually  to  50,  CO,  80  centigrammes  during  the  24  hours  (gr.  8 — 9 — 12). 
By  this  bold  use  of  the  remedy  many  observers  have  cured  cases;  the  list 
may  be  seen  in  the  "  Dictionnaire  de  therapeutique  "  of  MM.  Merat  and 
de  Lens,  t.  I.,  p.  401.     But  many  others  have  failed. 

While  nitrate  of  silver  is  powerless  against  epilepsy  in  almost  all  cases, 
it  succeeds  more  frequently  in  some  less  severe  neuroses,  especially  St. 
Vitus'  dance.  M.  Bretonneau  of  Tours  has  urged  this  treatment  more 
than  any  other  of  our  compatriots;  but  it  had  been  indicated  before  him 
("  Biblioth.  med.,"  t.  LI.,  p.  2G5;  Journ.  gen.  de  med.,  t.  LXXXVIL,  p. 
290;  Revue  med.,  dec,  1824,  p.  445). 

In  paralysis  agitans  MM.  Charcot  and  Vulpian  obtained  no  favorable 
results,  as  the  nitrate  only  increased  the  rigidity  and  tremor.  Bouchut 
claims  to  have  been  more  successful  in  general  progressive  paralysis,  but 
new  observations  are  evidently  required,  as  well  as  in  angina  pectoris.  In 
progressive  locomotor  ataxia  the  case  is  otherwise.  Wunderlich,  six  years 
ago,  struck  with  the  good  results  which  he  obtained  in  a  form  of  gener- 
alized paralysis  which  recurred  in  an  hysterical  woman  after  each  attack, 
used  it  in  locomotor  ataxia,  and  in  1861  published  five  cases,  in  each  of 
which  he  had  obtained  a  cure.  In  France  MM.  Charcot  and  Vulpian  have 
been  less  successful,  and  none  of  their  patients  have  been  radically  cured. 
Eulenburg  states  that  he  was  more  fortunate  last  year  and  obtained  one 
cure. 

It  has  been  used  in  whooping-cough;  Berger  seems  to  have  found  it 
very  serviceable  in  the  acute  stage,  and  when  the  convulsive  symptoms 
are  very  marked.  He  gives  it  in  the  dose  of  2 — 5  milligrammes  (gr.  O'OS 
0'08),  taken  at  first  three  times  and  afterwards  four  times  daily,  if  the 
condition  of  the  alimentary  canal  permits. 

Paralyses. — MM.  Charcot  and  Vulpian  have  some  belief  in  the  benefi- 
cial action  of  nitrate  of  silver  in  paraplegia  with  flaccidity  of  the  limbs, 
and  in  hysterical  paraplegia.  In  old  hemiplegia,  flaccidity  is  rarely  seen, 
but  contracture  produced  by  secondary  sclerosis  is  almost  always  present, 
in  which  case  silver  only  increases  the  contracture  and  produces  twitch- 
ings,  itching  and  formication.  The  preparations  of  silver  are  therefore 
chiefly  of  use  in  asthenic  paralysis  without  irritation  of  the  nervous 
centres. 

Diabetes. — One  of  us  has  improved  the  condition  of  a  diabetic  patient 
by  the  internal  use  of  nitrate  of  silver,  in  the  dose  of  5-10  centigrammes 
(gr.  0*8 — 1'5)  per  day,  for  two  weeks. 


192  THERAPEUTICS. 


Soda, 

Lactation. — In  the  treatment  of  nurses  and  suckling  children,  which 
fell  to  the  lot  of  one  of  us  at  the  hospital  Necker,  we  were  accustomed  to 
put  into  all  the  milk  which  was  given  the  children  half  a  gramme  (gr.  8) 
of  bicarbonate  of  sodium  per  litre  (quart).  This  has  two  advantages :  first, 
it  prevents  curdling,  which  easily  occurs  between  the  receipt  of  one 
day's  supply  and  that  of  the  next ;  and  second,  it  partly  neutralizes  the 
large  amount  of  acid  which  forms  in  the  alimentary  canal  of  children 
who  are  subjected  at  home — and  sometimes  in  the  hospital — to  a  detesta- 
ble regimen.  Owing  to  this  precaution,  diarrhoea,  which  is  so  fatal  to 
small  children,  especially  where  they  are  grouped  in  large  numbers,  was 
less  common  at  the  hospital  Necker  than  elsewhere.  If  the  diarrhoea  per- 
sists in  spite  of  these  precautions,  we  find  advantage  in  substituting  chalk 
for  bicarbonate  of  sodium. 

Stomachal  vertigo. — M.  Bretonneau,  we  think,  was  the  first  to  show 
positively  the  influence  of  certain  states  of  the  stomach  upon  the  func- 
tions of  the  brain.  He  observed  that,  in  a  very  large  number  of  cases, 
vertigo,  accompanied  by  trouble  of  the  heart  and  a  tendency  to  faintness, 
occurred  in  persons  who  at  the  same  time  complained  of  acid  eructations; 
in  this  case,  and  even  when  these  eructations  do  not  occur,  he  gives  for 
five  or  six  days  continuously,  three  times  a  day,  a  powder  composed  of  one 
gramme  (gr.  15)  of  bicarbonate  of  sodium,  and  half  a  gramme  of  carbonate 
of  magnesium.  Then  for  eight  or  ten  days  he  orders  to  be  taken  after  the 
two  meals,  half  a  glass  of  water,  in  which  2  grammes  (gr.  30)  of  quassia, 
cut  in  small  bits,  have  lain  for  24  hours. 

Angina  pectoris. — By  accident,  the  same  physician  found  that  a 
case  of  this  disease  was  cured  after  the  long-continued  use  of  bicarbonate 
of  sodium.  He  has  since  frequently  repeated  the  experiment,  and  quite 
generally  with  success;  but  in  this  case  he  continues  the  salt  for  more 
than  a  year,  and  returns  to  it  after  an  intermission  of  some  months. 
The  dose  ought  to  be  considerable — 2  to  10  grammes  (gr.  30 — 150)  per 
diem — and  in  most  cases,  after  he  has  made  a  decidedly  favorable  impres- 
sion on  the  disease,  he  adds  to  the  soda  the  powdered  root  of  bella- 
donna. 

Dyspepsia. — A  capital  fact  was  discovered  by  Proust,  and  confirmed 
by  Tiedemann  and  Gmelin,  to  wit:  that  the  empty  stomach  contains 
very  little  gastric  juice  ;  that  before  digestion  this  liquid  is  slightly  acid 
and  sometimes  even  neutral,  owing  to  the  ingestion  of  a  great  deal  of 
saliva;  that  the  gastric  juice  increases  after  the  ingestion  of  alimentary 
substances,  and  becomes  very  acid.  May  not  this  account  for  the  ex- 
treme variability  of  the  results  which  have  followed  the  use  of  potassa 
and  soda  as  lithontriptics,  and  might  not  a  practical  inference  be  drawn 
relative  to  the  time  and  manner  of  taking  them  ?     If  given  in  divided 


ALTERATIVES.  193 

doses,  at  distant  intervals,  and  very  near  a  meal,  when  gastric  juice 
abounds,  they  will  always  meet  enough  hydrochloric  acid  to  be  converted 
into  chlorides  (Lambossy:  "Considerations  physico-chimiques  relatives  a 
I'absorption  des  medicaments  mineraux;"  These,  Strasbourg,  22  avril, 
1836.)  Nevertheless,  the  analyses  of  gastric  juice  which  have  been  made 
by  Claude  Bernard  and  Barreswil  inform  us  that  muriatic  acid  is  rarely 
found  free  in  the  stomach;  the  acidity  of  gastric  juice  is  chiefly  due  to 
lactic  acid. 

Blondlot  and  CI.  Bernard,  in  an  important  paper,  have  pointed  out 
the  difference  in  the  action  of  alkaline  carbonates,  when  concentrated  and 
when  largely  diluted.  If  bicarbonate  of  sodium  is  given  in  concentrated 
solution  or  in  crystals,  the  gastric  secretion  is  suspended;  while  if  greatly 
diluted,  it  first  saturates  the  free  acids  of  the  stomach,  and  then  produces 
a  very  abundant  gastric  secretion.  The  use  to  be  made  of  this  fact  is 
evident. 

Plethora. — Bicarbonate  of  sodium  has  of  late  been  very  much  used  in 
preference  to  the  other  alkaline  salts,  in  the  treatment,  both  preservative 
and  curative,  of  various  morbid  states,  chiefly  characterized  by  the  pre- 
dominance of  the  stimulant  nutritive  and  plastic  elements  of  the  blood. 
Such  a  condition  is  found  in  the  various  forms  of  physiological  or  morbid 
plethora,  rheumatic  and  gouty  affections,  and  the  whole  class  of  acute 
inflammations. 

There  is  scarcely  a  physician  who  does  not  daily  employ  solutions  of 
bicarbonate  of  sodium,  or  better,  natural  Vichy  water,  to  modify  the  ple- 
thoric condition  which  is  caused  by  too  succulent  food,  want  of  muscular 
exercise  and  intra-visceral  combustion,  a  condition  so  frequent  in  rich, 
sensual  and  unoccupied  persons,  especially  in  large  cities.  The  same 
remedy  is  often  indicated  in  persons  of  the  sanguine  temperament,  who, 
from  hereditary  influence  or  accidental  causes,  have  a  more  or  less  marked 
predisposition  to  congestions  and  apoplexy. 

In  these  conditions,  bicarbonate  of  soda  is  undeniably  useful  in  more 
than  one  way,  both  by  removing  the  embarrassment  of  the  digestive  or- 
gans which  is  often  connected  with  plethora,  and  by  modifying  the  crasis 
of  the  blood,  and  correcting  the  excess  of  acids  and  the  predominance  of 
the  plastic  elements. 

By  insisting  on  this  alterative  treatment,  yet  always  with  prudence 
and  reserve,  and  enjoining  the  use  of  a  proper  rule  of  living,  we  may 
benefit  this  tendency  to  plethora  and  this  habit  of  congestion  which,  in 
many  persons,  forms  an  incessant  danger  and  a  perpetual  torment;  it  is 
even  possible  in  some  cases  thus  to  prevent  cerebral  haemorrhage,  or  at 
least,  to  postpone  its  first  attacks  or  relapses. 

In  these  circumstances,  bicarbonate  of  soda  is  given  in  the  dose  of 
only  one  gramme  (gr.  15)  per  day.  This  is  continued  for  a  week  or  two, 
and  is  afterwards  gradually  increased  to  2  (gr.  30)  or  a  little  more,  with 
the  precaution  of  suspending  its  use  from  time  to  time,  and  never  making 
the  doses  too  large. 
13 


194  THERAPEUTICS. 

In  the  chapter  on  alterative  treatment  we  mention  the  importance  of 
the  part  played  by  alkaline  remedies,  especially  bicarbonate  of  sodium,  in 
the  treatment  of  inflammatory  diseases.  For  example,  in  pneumonia  and 
pleurisy,  as  well  as  in  acute  forms  of  articular  rheumatism,  it  is  certain 
that  alkaline  drinks,  at  the  head  of  which  stand  the  solutions  of  bicarbo- 
nate of  sodium,  are  a  very  useful  auxiliary  to  bloodletting. 

Bicarbonate  of  sodium  has  very  lately  been  used  in  acute  pneumonia  to 
the  exclusion  of  all  other  remedies,  and  is  said  to  have  had  success.  We 
find  no  trouble  in  believing  Ihis,  for  frank  pneumonia  is  one  of  those  dis- 
eases which  seem  to  adapt  themselves  most  readily  to  many  forms  of 
treatment,  including  the  expectant.  Nevertheless,  in  severe  cases,  it  Avill 
always  be  more  prudent  to  put  the  alkalines  in  the  second  place,  and  not 
needlessly  to  compromise  them  by  giving  them  the  precedence  over  more 
powerful  and  approved  remedies,  such  as  bloodletting  and  contra- 
stimulants. 

JJijihtheria. — Bicarbonate  of  sodium,  as  an  alterant,  seems  naturally  in- 
dicated in  diphtheritic  affections.  It  had  long  been  in  use  for  membranous 
angina  and  croup,  but  had  never  earned  such  a  place  by  any  results  ob- 
tained. However,  it  had  retained  the  modest  position  which  it  really  de- 
served, down  to  a  recent  time,  when  certain  brilliant  successes,  some  real 
but  purely  accidental,  others  doubtful  or  very  questionable,  called  the 
attention  of  the  public  very  loudly  to  the  remedy,  and  presently,  enthusi- 
asm coming  to  its  aid,  the  carbonate  of  soda  was  almost  taken  for  the 
specific  antidote  of  diphtheria,  and  even  of  croup. 

Such  enthusiasm  could  not  last,  and  calm  reflection  and  observation 
soon  showed  things  in  their  true  light.  Bicarbonate  of  sodium  has  not  been 
given  up;  but  when  it  is  used  in  membranous  angina  and  croup,  it  is  as- 
sociated as  an  auxiliary  with  other  more  active  remedies.  Owing  to  its 
alterant  and  antiplastic  action,  it  maybe  of  use  in  modifying  the  general 
diathesis  which  seems  to  preside  over  the  development  of  the  diphtheritic 
affection,  or  in  acting  topically  on  the  false  membranes  which  coat  the 
pharynx  or  the  air-passages,  and  promoting  the  softening  and  detachment 
of  the  membranes.  In  these  two  ways  it  may  be  useful,  but  it  is  far 
from  having  that  excessive  importance  which  had  been  ascribed  to  it. 

Gravel,  calculi. — All  the  alkaline  solutions,  and  especially  those 
charged  with  bicarbonate  of  sodium,  at  the  head  of  which  we  will  put  Vichy 
water,  possess  the  power  of  rendering  the  urine  alkaline  very  rapidly. 
This  property  led  to  the  idea  of  dissolving  vesical  concretions  or  calculi. 
Magendie  is  perhaps  one  of  the  first  who  expressed  this  idea  and  urged 
physicians  to  make  the  experiment. 

This  method  of  dissolving  calculi  had  been  long  known,  if  not  ex- 
pressly formulated  by  science.  The  many  remedies  called  lithontriptics, 
such  as  snail-shells,  recommended  by  Pliny,  the  famous  specific  of  Miss 
Stephens,  Saunders'  potion,  the  remedy  of  .Juride  and  Chittiks,  the  ptisan 
of  Mascagni,  etc.,  all  these  have  carbonates  of  sodium  or  potassium  for  their 
base,  and  their  unquestionable  success  is  due  to  the  fact  of  their  alkalinity. 


ALTERATIVES.  195 

Guided  by  these  empirical  facts,  and  by  more  recent  and  decided  ob- 
servations and  experiments,  due  to  such  eminent  chemists  as  Arcet  and 
Berzelius,  a  certain  number  of  physicians  responded  to  Magendie's  appeal, 
and  by  experiment  established  the  positive  solvent  efficacy  of  alkaline 
solutions  or  waters,  whether  given  in  drink  or  as  baths,  or  as  injections. 

The  leader  of  these  experiments  was  Dr.  Petit,  inspector  of  the  waters 
at  Vichy,  who  concluded  that  those  waters  "  act  not  only  by  increasing 
the  secretion  of  urine,  and  thus  facilitating  the  discharge  of  calculi,  but 
that  their  essential  and  most  pronounced  action  depends  on  a  communica- 
tion of  their  chemical  properties  to  the  urine,  which  is  thereby  enabled  to 
dissolve  and  disaggregate  the  calculi,  as  far  as  their  volume  and  chemical 
composition  permit  it." 

To  explain  the  destruction  of  a  great  number  of  calculi  upon  which 
the  alkaline  salt  has  no  direct  chemical  action,  M.  Petit  brings  forward 
the  following  consideration:  "Too  much  attention  cannot  be  given  to 
the  vesical  mucus,  which  mingles  with  the  calculous  matter,  is  interposed 
between  its  particles,  increases  their  adhesive  force,  and,  in  a  word,  acts 
like  a  cement.  The  calculus,  therefore,  contains  a  sort  of  agglutination 
of  animal  and  saline  substances.  The  waters  dissolve  the  saline  part, 
which,  deprived  of  its  cement,  is  deposited  in  little  lamellfe  and  is  ejected 
with  the  urine;  thus  they  may  act  on  phosphatic  calculi,  especially  those 
composed  of  ammoniaco-magnesian  phosphate,  almost  as  effectively  as  on 
uric  acid."  He  infers  that,  even  when  the  waters  do  not  chemically  act 
upon  the  elements  of  a  calculus,  whatever  its  composition,  they  may  by 
disintegrating  the  components  diminish  them  by  degrees,  and  cause  their 
natural  expulsion  from  the  bladder. 

This  claim  on  behalf  of  the  Vichy  waters,  that  they  act  upon  all  cal- 
culous concretions  without  exception,  has  necessarily  met  with  much  con- 
tradiction. Some  have  denied  the  truth  of  the  facts,  that  is,  of  the  solu- 
tion of  the  calculi,  whatever  their  composition ;  in  proof  of  which  they 
offered  direct  experiments  in  which  calculi,  exposed  to  contact  with  Vichy 
water  in  or  out  of  the  bladder,  underwent  no  diminution  in  weight  or  alter- 
ation in  texture.  Others,  and  the  more  numerous  party,  while  admitting 
in  general  the  favorable  action  of  the  waters  in  certain  calculous  affec- 
tions, especially  gravel,  opposed,  and  with  good  reason,  the  too  exclusively 
chemical  explanation  which  was  offered. 

Passing  over  the  exaggerations  and  the  false  explanations,  to  which 
time  has  done  justice,  we  can  say  that  the  Vichy  water  has  gained  its 
cause;  and  no  one  can  now  question  the  efficacy  of  alkaline  waters,  espe- 
cially those  of  Vichy,  in  gravel — an  efficacy  attested  by  cures,  to  which 
most  physicians  can  bear  witness. 

There  is,  however,  a  distinction  to  be  made  between  the  different 
kinds  of  gravel.  They  may  bo  divided  into  two  chief  groups:  1,  those 
due  to  uric  acid  and  its  compounds;  2,  those  caused  by  phosphatic 
deposits. 

The  value  of  alkaline  solutions  in  uric  acid  (red)  gravel,  the  only  kind 


196  THERAPEUTICS. 

which  is  caused  by  a  true  diathesis,  is  almost  universally  admitted.  Ex- 
perience has  shown  very  positively  that  the  use  of  alkaline  salts,  and  par- 
ticularly, a  season  or  several  seasons  at  the  Vichy  Springs,  favor  the  ex- 
pulsion of  the  gravel  and  seem  to  assist  in  preventing  new  formations  for 
some  time. 

But  this  unanimity  is  not  found  in  regard  to  phosphatic  gravel,  the 
white  variety.  In  the  latter  case  the  urine  loses  its  acidity  and  becomes 
neutral  or  alkaline.  At  first  view,  the  chemical  theory  seems  to  forbid 
the  use  of  alkaline  waters;  and  we  know  that  savants  of  the  first  rank, 
including  Marcet  and  Prout,  have  made  objections,  apparently  of  great 
force  and  justice,  to  this  remedy.  But  other  chemists,  not  less  distin- 
guished, particularly  M.  Mialhe,  have  attempted  to  bring  equally  convin- 
cing arguments  on  the  other  side. 

We  shall  leave  the  chemical  question  to  the  chemists,  and  confine  our- 
selves to  observation  and  clinical  facts.  If,  on  consulting  the  facts,  we 
find  that  the  alkaline  treatment  does  not  possess  in  phosphatic  gravel  the 
same  evident  efficacy  which  it  displays  in  uric  acid  gravel,  we  think, 
nevertheless,  that  it  does  render  valuable  service  in  the  former  cases. 

Phosphatic  gravel  does  not  depend  upon  any  general  state  of  the  sys- 
tem, as  does  uric  acid  gravel;  it  is  a  purely  local  affection,  usually 
seated  in  the  bladder.  It  is  almost  always  due  to  a  catarrh  of  that  organ ; 
in  which  case  the  urine  is  retained  by  an  obstacle  to  its  free  passage,  and 
becomes  subject  to  an  ammoniacal  decomposition. 

Not  to  speak  of  the  chemical  reactions,  which  are  said  by  some  authors 
to  exercise  in  this  case  a  local  action  very  advantageous  in  the  affec- 
tion of  the  bladder,  there  are  yet  other  facts  which  seem  to  speak 
in  favor  of  Vichy  water.  It  is  said  that  large  quantities  of  mineral  water, 
introduced  into  the  system,  cause  a  continual  renewal  and  increase  of  the 
urinary  secretion,  dissolving  purulent  mucosity,  modifying  beneficially  dis- 
eased surfaces,  arresting  the  formation  of  ammoniacal  products;  and  that 
in  this  way  we  remove  by  degrees  the  cause  of  the  deposit,  and  the  pre- 
cipitation, and  attack  the  disease  at  its  source. 

In  brief,  it  is  by  an  almost  identical  action,  that  is,  by  the  introduction 
of  a  large  quantity  of  carbonate  of  soda  into  the  system,  that  Vichy  water 
is  useful  in  most  affections  of  the  urinarv  passages  which  are  character- 
ized by  gravel  or  calculous  concretions.  While  modifying  the  pathologi- 
cal state  of  the  vesical  mucous  membrane  and  liquefying  the  mucus,  it  also 
acts  on  the  composition  of  the  blood,  preventing  the  formation  of  uric 
acid  or  neutral  phosphates,  and  thus  changing  the  constitution  of  the  uri- 
nary principles  so  that  on  reaching  the  kidney's  and  bladder  they  no  longer 
contain  insoluble  substances  adapted  to  form  precipitates  (^Extract  from 
a  notice  of  the  Vichy  waters,  1854). 

In  this  method  of  stating  the  action  of  alkalines  upon  affections  of  the 
nrinary .passages,  which  seems  to  express  the  present  leading  opinion 
among  the  physicians  of  Vichy,  we  are  glad  to  see  that  there  remains 
something  which    is  not  reduced  (as  in   the  past)  to  a  purely  chemical 


ALTERATIVES.  197 

action;  that  the  success  of  the  treatment  tends  to  be  referred,  at  least  in 
a  very  large  share,  to  the  physiological  influence  exercised  by  the  treat- 
ment, both  upon  the  system  and  upon  the  diseased  organs. 

Can  a  real  and  durable  cure  be  conceived  of  as  effected  without  a  gen- 
eral and  profound  modification  of  the  whole  system — an  action  of  the 
remedy  upon  the  morbid  diathesis,  when  the  latter  is  universally  recog- 
nized as  the  true  cause  of  the  disease? 

In  other  words,  how  else  can  we  interpret  the  remarkable  and  constant 
fact,  that  persons  who  have  taken  alkaline  waters  for  several  months,  and 
who  .have  been  relieved  of  gravel  while  taking  them,  remain  for  several 
months  and  years  without  forming  new  gravel,  after  ceasing  to  use  the 
alkali  ?  In  this  case,  are  we  not  absolutely  forced  to  admit  that  under 
the  alkaline  treatment  not  only  does  the  urine,  ceasing  to  be  acid,  become 
unable  to  form  new  calculi,  but  that  the  remedy  has  modified  the  kidneys, 
or  the  digestive  organs,  or  the  whole  economy,  so  that  the  entire  diathe- 
sis, in  a  word,  if  not  destroyed  to  its  foundation,  is  at  least  restricted  in 
its  manifestations  ? 

Gout. — In  the  chapter  on  alterative  treatment  we  shall  speak  of  the 
nature  of  the  curative  action  of  alkaline  drinks,  and  especially  of  Vichy 
water,  in  gout.  The  physicians  at  Vichy  are  not  agreed  upon  this  point. 
Our  own  experience  has  been  as  follows: 

The  disease  is  very  rarely  cured  radically  by  this  treatment;  we  may 
even  sa\^  that,  in  the  case  of  hereditary  and  strongly  constitutional  gout, 
the  remedy  is  usually  impotent. 

But  we  cannot  deny  that  in  cases  of  simple  regular  gout,  its  effects  are 
more  marked;  the  frequency,  the  duration,  and  the  intensity  of  the  attacks 
are  usually  lessened,  and  sometimes  the  local  accidents  are  caused  to  dis- 
appear. Though  it  usually  has  but  little  action  on  nodes  and  other  to- 
phaceous concretions  about  the  joints,  it  nevertheless  easily  resolves,  to 
some  extent  at  least,  the  engorgements  which  proceed  from  rigidity  of  the 
ligaments  and  contraction  of  muscles. 

To  tell  the  truth,  Vichy  water  in  a  good  many  cases  produces  an  im- 
mediate aggravation  of  symptoms,  or  various  accidents  after  a  lapse  of 
time.  Tlie  bad  results  are  chiefly  found  in  abnormal  and  irregular  gout, 
especially  in  the  atonic  form.  And  to  be  frank,  we  have  good  reason  to 
think  that  the  Vichy  waters  have  repeatedly  caused  metastases,  which 
have  proved  fatal. 

We  need  not  repeat  what  has  been  said  above  as  to  the  danger  of  the 
abuse  or  the  untimel}'^  use  of  alkalines. 

In  the  treatment  of  gravel,  the  sesquicarbonate  or  bicarbonate  of 
sodium  is  given  for  two  or  three  months  in  the  dose  of  from  2  to  30  grammes 
per  day  (gr.  30 — 450),  in  one,  two,  or  three  quarts  of  water. 

Diabetes. — The  utility  of  alkalines  in  diabetes  was  known  in  the  last 
century.  Lime-water  was  then  prescribed  as  a  means  of  relieving  the  ex- 
cessive thirst  and  diminishing  the  renal  secretion.  Veterinarians  were  very 
successful  in  curing  a  disease  of  horses  called  la  pisse,  by  giving  Spanish 


198  THERAPEUTICS. 

white  mixed  with  water.  At  present,  an  infinite  variety  of  alkalines  is 
given;  carbonate  of  lime,  bicarbonate  of  sodium,  magnesia,  etc.  But 
these  remedies  do  not  act  in  the  system  as  they  do  upon  sugar  in  the  test- 
tube.  They  act  as  powerful  modifiers  of  nutrition,  placing  the  patient  in 
special  conditions,  by  virtue  of  which  the  abnormal  production  of  sugar 
ceases  to  occur.  We  should  not  seek  to  produce  absolute  alkalization; 
these  remedies  must  be  given  simply  as  adjuvants,  in  moderate  dose,  and 
only  for  a  certain  time,  eight  or  ten  days  in  each  month,  and  no  more. 

AphtliCB. — Professor  Gubler  has  shown  that  the  presence  of  aphthae  is 
connected  with  suppression  or  great  diminution  of  the  saliva  with  pa,rtial 
dryness  of  the  mouth  and  collection  of  the  products  of  epithelial  desqua- 
mation, to  which  are  added  fermentable  alimentary  substances.  Acidity 
of  the  mouth  commonly  denotes  the  presence  of  spores  in  the  mucus,  and 
indicates  that  clusters  of  oidium  albicans  are  about  to  appear,  Gubler 
deduces  the  rational  rule,  that  all  alkalines  cure  aphthae;  he  usually  em- 
ploys bicarbonate  of  sodium. 


BOKAX  OR  BiBORATE  OF  SoDIUM. 

Stomatitis  and  angina. — Borax  is  chiefly  used  as  a  wash,  by  mixing  it 
with  equal  parts  of  honey,  or  in  the  proportion  of  a  fourth,  an  eighth,  a 
twelfth;  it  is  recommended  in  foul  ulcers  of  the  gums,  of  the  inner  aspect 
of  the  cheeks,  in  thrush,  and  pultaceous  angina  (Bisset,  Gooch,  Veryst, 
Starke,  Gmelin,  "  Apparat  med.,"  continuation  of  Murray,  Baup,  de  Hyon, 
*' Bibliotheque  de  Geneve,"  t.  XL.:  Recamier,  "Lemons  cliniques  de  la 
faculte  de  medecine  de  Paris").  In  cases  of  laryngeal  catarrh  we  prefer 
syrup  of  borax  to  gargles,  especially  for  children.  It  is  given  by  teaspoon- 
fuls  eight  or  ten  times  a  day,  with  the  precaution  of  not  drinking  imme- 
diately afterwards,  in  order  to  prolong  the  contact  of  the  salt  with  the 
affected  mucous  membrane. 

In  angina,  aphtha-,  thrush  in  children  or  even  in  adults,  it  is  often  suf- 
ficient to  use  it  in  a  wash,  sometimes  with  the  addition  of  opium  in  cases 
of  stomatitis  and  that  painful  angina  which  attends  fatal  cachexite 
(phthisis,  cancer,  cirrhosis,  etc.). 

Prxiritus  of  the  miicoxis  membranes  and  the  slcin. — In  vaginal  injec- 
tions it  is  useful  for  leucorrhoea  caused  by  a  slight  erosion  of  the  os  tineas; 
and  in  pruritus  of  the  male  and  female  genitals  (Dewees:  BihliotMqut 
m,edicale,  t.  LXIV.,  p.  136). 

In  certain  very  irritable  persons  it  is  a  good  substitute  for  sulphate 
of  zinc  or  copper  in  collyria,  calming  the  erethism  of  the  conjunctiva, 
and  acting  with  sufficient  energy  as  a  styptic. 

Hufeland  and  Recamier  have  brought  it  into  repute  in  our  times. 
Hufeland,  and  after  him  Reinard,  following  Starke  (see  Gmelin,  1.  c), 
order  it  dissolved  in  water  or  mixed  with  various  mucilages  for  the  treat- 
ment of  dry  superficial  diseases  of  the  skin  accompanied  by  a  very  pain- 


ALTERATIVES.  199 

f ul  feeling  of  itching  and  burning,  such  as  facial  eruptions,  and  frost- 
bites. {Journal  de  chimie  m'ecUcale,  t.  II.,  p.  591;  Archives  generales  de 
medicme,  t.  XVI.,  p.  137). 

Borax  given  internally,  has  a  certain  lithontriptic  value  in  uric  acid 
gravel  and  calculi,  by  virtue  of  its  alkalinity,  and  independently  of  its 
sedative  effect. 

Dysmenorrhcea. — Accouchement. — The  compiler  Gmelin  calls  attention 
(1.  c.)  to  another  property  upon  which  he  quotes  a  great  many  authori- 
ties. This  is  its  power  of  assisting  menstruation,  of  quieting  the  uterine 
pains  which  accompany  or  precede  the  function,  and  even  those  which 
appear  during  parturition;  of  producing  the  lochial  discharge,  etc.  It  is 
probable  that  borax  owes  these  qualities  to  the  soda  it  contains;  as  to  its 
special  action  on  the  uterus  during  parturition,  we  shall  wait  for  more 
evidence.  Hufeland  {Journal  d''  Huf eland),  Lobstein  (of  Strasburg) 
{Journal  de  medecine,  de  Leroux,  t.  XXXVI.,  p.  107),  Van  Krassen- 
donck  {Bxdletin  des  sciences  medicales  de  Ferrussac,  t.  XL,  p.  275),  also 
recommend  it  for  rendering  the  labor-pains  regular  and  for  reviving  the 
uterine  contractions;  but  Duchateau,  who  used  it  for  the  same  purpose 
and  in  the  same  doses,  states  that  he  derived  no  benefit  from  it  (Societe 
d'emulation,  novembre,  1876). 

We  must  add  that  Dr.  Spengler  of  Ems  has  more  recently  sought  to 
define  more  precisely  the  indications  for  this  medicine.  He  believes  that 
borax  is  of  especial  use  when  the  woman  is  suffering  from  exaltation  of 
sensibility,  where  there  exists  a  spasmodic  condition  of  the  uterus  which 
opposes  the  act  of  parturition,  and  is  accompanied  with  cramps  and 
pains.  If  this  be  so,  borax  is  indicated  in  conditions  precisely  the  re- 
verse of  those  where  ergot  of  rye  is  demanded.  The  internal  dose  is 
from  2  to  4  grammes  (gr.  30 — 60). 


Lime. 

Acescejice,  pyrosis,  acid  dyspepsia. — Infantile  diarrhoea. — For  the  first 
six  months  of  life,  the  fluids  of  the  infant's  mouth  are  normally  acid;  and 
the  stools  are  also  often  acid,  especially  when  they  have  that  greenish 
tint  which  so  often  replaces  the  normal  yellow.  This  green  color  is  due 
to  a  blue  substance,  which  often  appears  as  such  on  the  diaper,  and,  with 
the  yellow  color  of  the  faeces,  forms  a  green  of  varying  depth.  When 
the  alteration  is  slight,  the  blue  color  is  not  produced  until  several  hours 
after  the  fasces  are  expelled,  and  appears  first  upon  the  diaper,  afterwards 
on  the  parts  of  the  fteces  that  are  exposed  to  the  air.  But  when  the 
alteration  is  greater,  the  entire  mass  is  affected,  and  the  color  appears 
shortly  after  defecation,  or  before,  and  the  fasces,  as  passed,  are  of  a  very 
strong  green,  almost  blue. 

This  acescence,  often  associated  with  diarrhoea  and  erythema  of  the 
buttocks  and  thighs,  is  remarkably  benefited   by  mixing  lime-water  with 


200  THERAPEUTICS. 

the  milk  in  the  proportion  of  a  fourth,  or  by  giving  it  in  sweetened  water, 
if  the  child  is  at  the  breast. 

In  the  adult,  the  buccal  mucus,  mixed  with  saliva,  generally  has  an 
alkaline  reaction,  and  the  acidity  of  the  mouth,  when  it  exists,  almost 
always  accompanies  that  of  the  stomach. 

The  painful  acidity  or  burning  sensation  at  the  stomach,  pyrosis,  is 
not  produced  by  an  excess  of  gastric  juice,  but  by  the  acids  which  are 
formed  at  the  close  of  the  fermentation  of  starchy  matters,  wine,  and  alco- 
holic liquors.  The  acid  regurgitation  occurring  long'  after  eating,  when 
the  starchy  substances  are  not  digested,  may  have  been  rightly  inter- 
preted by  Galen;  for  he  says  that  it  occurs  when  there  is  an  acid  corrup- 
tion of  the  food  in  the  stomach. 

This  affection  is  remarkably  improved  by  alkalines,  and  in  particular 
by  lime  given  under  the  form  of  mineral  lime-water,  or  of  pastilles  con- 
taining tribasic  phosphate  of  lime.  M.  Delpech  has  made  tablets  of  the 
gelatinous  tribasic  phosphate  with  gum  tragacanth,  which  gives  the  best 
results. 

Lime  is  the  best  of  all  alkalines,  if  there  is  diarrhcBa ;  but  if  there  is 
constipation,  preparations  containing  soda  or  potassa  should  be  preferred. 

To  young  children  suffering  from  acidity,  with  vomiting  and  diarrhoea, 
we  may  give  powdered  oculi  cancrorum,  in  the  dose  of  0'3 — O'G  (gr.  3 — 9); 
for  adults  the  usual  dose  is  4  grammes  (  3  i-). 

Diarrhoea. — In  chronic  diarrhoea,  in  those  due  to  ulceration  of  the 
intestine,  more  particularly  the  large  intestine,  lime-water,  used  as  a 
drink  or  an  injection,  has  been  used;  Bretonneau,  of  Tours,  has  praised  its 
effect  in  the  diarrhoea  which  retards  convalescence  from  dothinenteritis 
and  dysentery.  In  the  former  disease  he  used  to  give  lime-water,  from 
30  to  GO  grammes  a  day  shaken  with  warm  sweetened  milk;  in  dysentery 
he  used  it  in  the  same  way,  at  the  same  time  ordering  a  whole  injection 
morning  and  evening,  which  contained  from  120  to  200  grammes  (  3  iv. — 
vi.)  of  lime-water,  and  3  or  4  drops  of  Rousseau's  laudanum. 

Phthisis. — M.  J.  Guyot,  having  a  phthisical  patient  at  the  hospital 
St.  Antoine,  who  had  used  phosphate  of  lime  to  arrest  night-sweats,  con- 
tinued to  use  the  medicine,  and  applied  it  to  many  other  similar  cases. 
In  a  few  it  failed;  in  a  greater  number  the  sweats  lessened  or  disap- 
peared. M.  Guj-ot  in  some  cases  was  able  to  suppress  and  to  restore  the 
sweats  with  certainty  by  giving  or  withholding  the  phosphate  of  lime. 
The  dose  varied  from  2  to  6  grammes  per  day  {Bulletin  de  tli'erapeutique, 
1870,  t.  I.,  p.  140). 

Dr.  Beneke,  of  London,  recommends  phosphate  of  lime  in  phthisical 
diarrhoea.    We  often  use  the  following  formula  of  Fremy's  in  consumption: 

Hypophosphite  of  lime 12  grammes  (  3  iii-)' 

Ammonio-citrate  of  iron 8  "  (  3  ii-)- 

Cinnamon  powder )  j.      o<  j 

_          .         ^  r  Q-  s.  lor  24  powders. 

Benzoin ) 


ALTERATIVES.  201 

Hachitism. —  Osteomalacia. — Phosphate  of  lime  was  recommended  for 
rachitism  in  1703,  by  Bonliomme,  of  Amiens,  but  was  not  adopted  in  regu- 
lar practice,  in  spite  of  the  praise  of  Halle,  and  the  experiments  of  Chos- 
sat.  In  1814  Piorry  took  up  the  remedy,  thinking,  like  his  predecessors, 
that  he  could  deposit  phosphate  of  lime  in  the  bones  where  it  was  wanted. 
He  prescribed  the  powder  of  scraped  bones.  In  1852  M.  Mouries  im- 
prov'ed  on  this,  by  giving  the  phosphate  in  small  doses  mixed  with  an  al- 
buminoid matter,  which,  unfortunately,  is  too  often  acid.  The  remedy 
has  been  twice  abandoned:  it  has  been  tried  for  a  third  time,  but  will 
probably  soon  be  given  up  once  more. 

The  latest  experiments  are  as  follows  : 

We  know  that  the  bones  are  liable  to  changes  which  produce  soften- 
ing, deformity  and  fragility.  These  changes  may  occur  in  infancy,  con- 
stituting rachitism;  in  adult  life  they  are  called  osteomalacia,  and  in  old 
age,  senile  osteomalacia.  Nevertheless,  there  is  more  than  a  simple  ques- 
tion of  age;  the  affection  in  infancy  differs  from  the  softening  of  adults, 
and  the  latter  does  not  resemble  that  of  old  men.  The  microscopical  le- 
sions of  rachitism  are  not  absolutely  the  same  as  in  osteomalacia;  they 
proceed  from  arrested  development,  while  the  affection  in  the  adult  is  a 
real  atrophy,  or  rather,  as  is  now  said,  a  detrophy.  It  is  possible  that 
this  detrophy  may  be  found  not  to  be  a  primary  affection,  but  the  common 
element  in  determinable  pathological  conditions. 

As  to  the  senile  atroph}'^  which  causes  fractures  or  deformity  of  the 
bones,  it  is  a  well-known  affection  of  old  age,  in  animals  as  weli  as  in  man, 
in  regard  to  which  the  most  complete  information  may  be  found  in  the 
th^se  of  Paul  Bouley  (Paris,  1871). 

In  animals,  osteomalacia  has  always  been  produced  by  the  same  cause — 
an  excessively  dry  summer,  which  makes  the  fodder  poor  in  important  min- 
erals. Phosphate  of  lime  has  been  given  in  all  forms  to  these  animals 
without  satisfactory  results;  while  they  have  been  completely  cured  by 
transferring  them  to  places  where  the  forage  was  richer. 

We  will  say  as  much  of  rachitism;  it  is  much  easier  to  cure  it  by 
rich  food  than  by  phosphate  of  lime,  Rachitism  and  osteomalacia  are  no 
more  cured  by  phosphate  of  lime,  than  anjemia  is  by  drinking  blood,  or 
neuroses  by  eating  brain. 

It  does  not,  however,  follow  that  lime  should  not  be  given  to  such  pa- 
tients. We  can  say  here  what  we  said  of  iron.  The  preparations  of  lime 
are  much  more  efficient  by  their  action  upon  the  digestive  tract  than  by 
their  transportation  in  substance  to  the  bones. 

The  preparations  which  we  have  found  most  efficient  in  rachitism  and 
osteomalacia  are  lime-water  and  saccharate  of  lime.  Food  may  be  taken 
which  contains  much  phosphate  of  lime,  as  army-bread  (containing  a  cer- 
tain amount  of  bran),  and  beans  and  haricots. 

Fractures. — M.  Alphonse  Milne-Edwards  supposed  that  by  the  addi- 
tion of  a  certain  quantity  of  phosphate  of  lime  to  the  diet  a  portion  might 
be  fixed  in  the  callus.     He  gave  it  to  wounded  persons  under  the  care  of 


202  THERAPEUTICS. 

M.  Gosselin,  and  to  animals,  as  rabbits,  in  whom  he  had  produced  frac- 
tures. His  conclusion  is,  that  he  accelerated  the  ossification  of  the  callus, 
and  that  the  treatment  might  obviate  to  some  extent  the  danger  of  non- 
consolidation  i^Bulletin  de  therapeutlque,  1856).  The  practice  was  taken 
up  by  M.  Fano  (  Union  niedicale,  1859,  t.  III.,  p.  24),  but  has  since  fallen 
into  disuse. 

Lymphatism. — M,  Mouries  states  that  phosphate  of  lime  plays  a  more 
important  part  in  animals  than  has  hitherto  been  supposed.  Indepen- 
dently of  its  influence  upon  ossification,  the  salt  has  a  special  action  upon 
irritability,  without  which  neither  assimilation  nor  nutrition  could  take 
place.  An  extreme  deficiency  of  this  principle  produces  death  with  all 
the  symptoms  of  inanition,  and  a  deficiency  in  a  less  degree  produces 
numerous  affections  which  are  connected  with  lymphatism.  M.  Mourios, 
by  his  examinations  and  analyses,  has  been  led  to  the  conclusion  that  the 
food  of  the  inhabitants  of  cities  is  usually  defective  in  this  point,  the 
daily  quantity  consumed  by  Avomen  in  cities  being  less  than  half  that 
which  is  needful  (6  grammes  or  3  iss.)  to  the  economy.  As  a  conse- 
quence, he  shows  that  the  milk  of  nurses  in  cities  is  poor  in  fixed  salts, 
and  particularly  in  phosphate  of  lime.  Hence,  the  foetus  and  the  young 
infant  must  suffer  considerably  from  the  absence  of  a  substance  which  is 
indispensable  to  their  existence  and  development.  This  is  one  of  the 
chief  causes  of  the  enormous  excess  in  the  number  of  still-born  children, 
of  the  prevalence  of  so  many  diseases  among  infants,  and  their  very  great 
mortality  in  large  cities. 

To  remedy  this  evil,  M.  ?iIouries  proposes  to  add  to  the  diet  of  preg- 
nant women,  wet-nurses  and  infants,  the  nutritive  principle  which  is  de- 
ficient. It  is  his  plan  to  associate  phosphate  of  lime  with  an  albuminous 
substance;  and  he'has  prepared  a  kind  of  fine  bread  or  paste,  which  is  to 
be  given  in  soup  to  nurses  or  mothers  or  children,  whenever  there  is  rea- 
son to  think  that  the  phosphate  of  lime  is  deficient  in  the  food  or  the 
milk,  or  whenever  the  child's  health  seems  to  require  it. 

In  support  of  these  wholly  theoretic  considerations  he  presents  a  cer- 
tain number  of  cases  in  which  this  kind  of  food  is  said  to  have  lessened 
the  number  of  still-births  in  certain  families,  to  have  diminished  the  num- 
ber of  lymphatic  diseases  in  children,  and  even  to  have  aided  in  curing 
them  when  not  prevented.  Among  the  affections  akin  to  lymphatism 
which  may  be  thus  benefited,  he  names  debility  from  birth,  rachitis,  devia- 
tion of  the  spine,  deformity  of  the  bones,  retarded  dentition,  and  slow 
growth. 

These  ideas  have  supporters  abroad.  Dr.  Beneke,  physician  to  the 
Dalston  German  hospital  in  London,  published  a  paper  in  the  Lancet  of 
April  19,  1851,  Avhich  tends  to  the  same  conclusions:  he  points  out  the 
importance  of  phosphate  of  lime  in  growth,  and  regards  scrofulous  patients 
as  deficient  in  this  salt.  Hence  he  has  treated  ulcerous  scrofulidas  by  the 
internal  administration  of  lime,  and  claims  great  success. 


ALTERATIVES.  203 


Baryta. 

Chloride  of  barium  has  for  some  years  enjoyed  a  certain  reputation  in 
the  treatment  of  white  swellings.  Crawford,  in  1780,  was  the  first  to 
recognize  its  good  effect  in  scrofula.  More  lately,  Professor  Scassi  of 
Genoa,  has  made  investigations,  and  since  then,  in  Italy,  MM.  Mojon, 
Nongiardini,  Ferrari,  etc.,  have  had  good  results,  while  in  France,  at 
the  instigation  of  Pirondi,  the  Italian  experiments  have  been  repeated  at 
La  Pitie  by  Lisfranc,  with  incontestable  success. 

The  mode  of  administration  is  as  follows: 

Lisfranc  usually  began  with  a  mixture  of  30  centigrammes  (gr.  4|^)  in 
125  grammes  (say  4  oz.)  of  distilled  water,  of  which  the  patient  took  a 
tablespoonful  every  hour,  except  an  hour  before  and  two  hours  after 
meals.  The  patient,  in  order  to  endure  this  medicine,  must  abstain  from 
wine  and  flesh,  and  confine  himself  to  pure  water  and  vegetable  diet.  At 
the  end  of  a  week,  if  no  acidents  occur,  he  doubles  the  quantity  of  the 
salt  in  the  same  amount  of  water,  and  thus  continues  to  increase  gradu- 
ally, giving  in  some  eases  as  much  as  3  grammes  (gr.  45). 

The  unpleasant  symptoms  which  may  oblige  the  patient  to  suspend 
the  use  of  the  remedy  for  some  days,  consist  of  pain  about  the  stomach, 
nausea,  vomiting,  etc.  These  first  symptoms  of  poisoning  are  readily 
dissipated  by  the  white  of  an  egg,  or  by  sugared  wine,  as  M.  Pirondi  has 
advised  {Bulletin  de  th'erap.,  t.  X.,  lie  livraison). 


LiTHIA. 

Gravel. — Garrod  claims  to  have  established  the  action  of  carbonate 
of  lithium  when  given  internally.  He  has  used  it  several  years,  in  cases 
of  uric  acid  diathesis  connected  with  gravel,  and  in  chronic  gout,  and  has 
always  obtained  the  most  satisfactory  results.  Taken  internally,  twice 
or  three  times  a  day  in  the  dose  of  from  one  to  four  grains  dissolved  in 
water,  it  produces  no  direct  physiological  action ;  but  in  persons  who  pass 
uric  acid  gravel,  it  has  a  marked  influence  by  lessening  the  amount  of  the 
deposits,  or  arresting  them  entirely.  As  there  have  never  been  any  bad 
consequences,  Garrod  considers  this  remedy  the  most  suitable  to  drive 
away  attacks  of  gout  and  improve  the  patient's  condition. 

Gout. — Carbonate  of  lithium  is  by  no  means  destined  to  replace  col- 
chicum.  Its  use  is  in  chronic  gout.  It  is  valuable  for  preventing  the 
return  of  attacks,  and  for  dispersing  the  remnants  of  the  disorder.  In 
certain  cases  it  has  caused  old  nodules  to  disappear  which  were  supposed 
incurable. 

M.  Charcot  quotes  in  particular  ("  Garrod  on  Gout,"  p.  490)  the  case 


204  THERAPEUTICS. 

of  a  woman  aged  77,  who  had  been  treated  for  tophus,  at  Wiesbaden, 
without  success,  and  afterwards  used  the  followihg  drink: 

Carbonic-acid  water 500  grm.  =  |  xvi. 

Bicarbonate  of  sodium 0*25  grm.=gr.  iv. 

Carbonate  of  lithium O'lO     "     =gr.  iss. 

The  concretions  were  said  to  have  disappeared  in  two  weeks.  Char- 
cot does  not  guarantee  the  fact,  given  by  Strieker,  and  we  understand 
him;  but  as  he  thinks  it  worthy  of  mention,  we  follow  his  example  in 
desiring  physicians  to  try  this  remedy,  which,  if  it  do  not  disperse  the 
tophus,  will  produce  no  bad  effect  ("  Grarrod  on  Gout,"  etc.). 

Ure  has  proposed  to  inject  carbonate  of  lithium  into  the  bladder  to 
dissolve  urinary  calculi. 

Ammonia. 

Spasmodic  diseases. — Cullen  regarded  ammonia  as  the  best  antispas- 
modic. M.  Levrat-Perroton  has  praised  its  effect  in  whooping-cough. 
It  has  been  recommended  in  cases  of  migraine,  in  doses  of  5  or  6  drops 
in  an  infusion  of  tilia  or  orange-leaves.  Dr.  Baraillier,  of  Toulon,  states 
that  in  attacks  of  nervous  headache,  muriate  of  ammonium  relieves  almost 
instantly;  he  gives  3  grammes  (gr.  45)  in  3  doses,  in  solution,  with  half 
an  hour's  interval  between  the  doses.  We  shall  not  speak  of  the  advan- 
tages of  ammonia  in  paralysis.  It  is  too  evident  that  we  cannot  attach 
great  confidence  to  what  Bichat  says  upon  this  point,  according  to  Jahan 
de  la  Chesne  {Jouni.  de  med.,  t.  XIX.,  p.  2G0).  Fournier  Pescay  and 
Fran9ois  d'Auxerre  regarded  it  as  the  most  trustworthy  remedy  in 
tetanus  ("Diet,  des  sciences  med.,  t.  LV.,  p.  31);  the  dose  in  this  case 
should  be  large,  and  may  be  as  much  as  15  grammes  (in  divided  doses) 
per  day  [gr.  230]. 

M.  Martinet  believed  that  an  epileptic  patient  might  prevent  an 
attack  from  coming  on,  if  he  swallowed  a  draught  containing  ammonia 
during  the  initial  symptoms. 

Diabetes. — In  speaking  of  soda  and  potassa  we  stated  that  they  had 
been  used  for  their  alkaline  properties  in  the  treatment  of  diabetes  mel- 
litus.  Certain  physicians,  struck  with  the  dryness  of  the  skin  of  diabetic 
patients,  and  hoping  to  produce  sweating  by  ammonia  or  its  carbonate, 
gave  it  as  a  sudorific;  they  observed  an  improvement  which  they  attribu- 
ted to  the  diaphoretic  action  of  the  remedy,  but  which  ought  rather  to 
have  been  attributed  to  its  alkaline  properties. 

Hodges  {London  Med.  Gaz.)  quotes  the  case  of  a  young  girl  of  seven- 
teen, extremely  diabetic,  who  passed  12  litres  (quarts)  of  urine,  in  24 
hours.  He  first  gave  25  centigrammes  of  carbonate  of  ammonium  every 
three  hours,  confining  the  patient  to  the  use  of  coffee,  bacon,  meat,  and 
vegetables  without  sugar.  The  disease  was  improved  in  four  daj's,  and 
cured  in  two  months  and  a  half. 


ALTERATIVES.  205 

Barlow  has  a  theory  which  approaches  the  truth.  He  thinks  (and  is 
the  only  one  who  has  the  belief)  that  the  increase  of  urine  is  caused  by 
the  diuretic  effect  of  the  sugar,  that  is,  its  excitant  action  upon  the  kid- 
nays.  He  prescribes  the  sesquicarbonate  in  the  dose  of  25 — 30  centi- 
grammes (gr.  4 — 5)  or  more,  with  a  few  drops  of  tincture  of  opium  in  a 
bitter  infusion,  to  be  repeated  every  six  hours;  the  diet  to  be  animal, 
with  antiscorbutic  plants.  He  reports  four  cases  in  support  of  this  treat- 
ment, but  carefully  states  that  he  is  far  from  offering  the  method  as  one 
which  must  succceed  in  all  cases  [British  and  Foreign  Med.  Review,  Oct., 
1841). 

Pneumatosis. — The  neutralizing  action  of  ammonia  has  been  employed 
very  successfully  by  veterinarians  in  case  of  gaseous  distention  of  the 
paunch  in  ruminants  {Bulletin  des  sc.  med.  de  Ferussac,  mai,  182G).  The 
animal  takes  a  drench  containing  a  large  quantity  of  ammonia,  which 
unites  with  the  carbonic  acid  gas  that  distends  the  stomach,  relieves  the 
meteorism  at  once,  and  arrests  the  fermentation  of  the  mass  of  food. 
This  plan  ought  to  be  adopted  for  the  treatment  of  persons;  it  is  stated 
by  chemists  that  carbonic  acid  forms  a  large  part  of  the  gases  which  are 
naturally  or  accidentally  developed  in  the  digestive  passages.  The  value 
of  such  draughts  or  injections  is  easily  seen  in  certain  cases  of  meteorism. 

Acidity. -^AmmonvA  acts  in  the  same  way  in  the  treatment  of  poison- 
ing by  acids,  and  in  that  of  acidity  of  the  stomach;  the  formula  advised 
by  Chevallier  in  the  latter  case  is  the  following:  Distilled  water,  150 
grammes  (about  §v.);  water  distilled  from  mint,  15  grammes  (gr.  230); 
ammonia,  3  drops;  to  be  taken  in  one  or  two  parts  (Journal  des  connais- 
sances  med.-chir.,  t.  I.,  p.  342). 

AlcoJiolism. — In  poisoning  by  alcohol  and  animal  venoms  the  virtues 
of  the  volatile  alkali  have  been  exaggerated  in  the  most  ridiculous,  not  to 
say  the  most  mendacious  manner.  In  slight  intoxication,  as  is  shown  by 
the  observations  of  Girard  and  Chevallier  {Revue  medicale,  nov.,  1823), 
and  Piazza  {Bull,  de  therap.,  t.  VII.,  1834),  a  dose  of  15  or  20  drops  of 
ammonia  in  a  glass  of  sweetened  water  is  useful,  though  Chantourelle 
brings  facts  upon  the  opposite  side;  but  when  intoxication  is  profound, 
the  alkali  is  insufficient.  Nevertheless,  we  ought  to  say  that  M.  Rigal 
{Arch.  gen.  de  med.,  t.  XVII.,  p.  601),  gives  an  account  of  a  beggar, 
dead-drunk,  who  could  not  be  restored  except  by  giving  him  8  drops,  and 
afterwards  4  drops  of  ammonia. 

M.  Tessier  of  Lyons,  who  has  great  confidence  in  ammonia,  and  con- 
siders it  one  "of  our  best  alexipharmaca,  claims  to  have  used  it  with  bene- 
fit in  certain  permanent  lesions  resulting  from  the  abuse  of  alcoholic 
drinks,  as  amblyopia,  and  in  diseases  caused  by  the  emanations  of  tobacco- 
leaves. 

M.  Scharn,  after  trying  in  vain  all  the  remedies  which  have  been  recom- 
mended for  the  chorea  of  drunkards,  conceived  the  idea  that  this  disease, 
being  merely  drunkenness  at  its  apogee,  ought  to  be  treated  by  the  reme- 
dies which  are  successful  in  the  latter,  and  that,  consequently,  ammonia 


206  THERAPEUTICS. 

ought  to  be  perfectly  adapted  to  all  the  requirements  of  such  cases. 
With  this  evidently  false  idea  in  his  mind,  he  has  ordered  for  delirium 
tremens  the  liqueur  ammoniacale  pyro-huileuse  [crude  ammonia],  or  more 
simply,  succinate  of  ammonium;  by  which  simple  means  he  says  he  has 
seen  the  severest  symptoms,  the  most  furious  delirium,  conquered  as  by 
enchantment  after  a  few  hours,  without  any  other  remedy.  Brachet  of 
Lyons  has  more  recently  praised  ammonia  in  the  dose  of  15  drops  in  a 
glass  of  water  in  delirium  tremens  (Casper's  'Wochenschrift). 

Poisoning  by  hydrocyanic  acid. — Our  last  remarks  are  applicable  to 
poisoning  by  hydrocj'anic  acid.  We  have  been  witnesses  of  the  experi- 
ments of  Dupuy  at  Alfort,  intended  to  show  the  value  of  volatile  alkali 
and  of  carbonate  of  ammonium  in  the  treatment  of  this  kind  of  poisoning. 
We  can  state  that  a  horse,  poisoned  by  36  drops  of  Scheele's  prussic  acid, 
recovered  spontaneously  in  two  hours;  and  that  the  same  horse,  similarly 
poisoned  the  next  day,  and  treated  in  a  quarter  of  an  hour  by  the  carbon- 
ate of  ammonium,  recovered  as  before,  but  remained  longer  sick;  and  yet 
this  singular  fact,  the  most  important  circumstances  of  which  were  omitted 
in  the  telling,  produced  the  same  impression  as  that  of  Bernard  de  Jussieu, 
and  ammonia  was  regarded  as  the  antidote  of  hydrocyanic  acid  as  truly 
as  of  the  poisons  of  the  viper,  scorpion,  bee,  etc. 

The  principal  compounds  of  ammonia  used  in  medicine  are:  the  carbo- 
nate, the  acetate,  and  the  muriate. 


Carbonate  of  Ammonium. 

This  salt  is  strongly  alkaline,  and  owes  its  medical  virtues  entirely  to 
ammonia;  we  do  not  ascribe  to  it  any  special  virtues.  The  dose  is  twice 
as  large  as  that  of  ammonia. 

In  England  it  is  used  in  syncope  and  epilepsy,  being  inhaled,  with  pre- 
caution, from  a  wide-mouthed  vial.  Various  aromatic  essences  are  added 
to  the  salt. 

Peyrilhe,  and  after  him  Biett,  obtained  favorable  results  from  the  use 
of  the  subcarbonate  in  certain  inveterate  forms  of  syphilis,  especially  the 
syphilidfe.  M.  Cazenave,  imitating  them,  proposes  the  drug  as  a  substi- 
tute for  the  preparations  of  arsenic  in  certain  squamous  affections,  such 
as  psoriasis  and  lepra  vulgaris.  He  gives  each  day  from  one  to  three  large 
spoonfuls  of  the  following  mixture:  subcarbonate  of  ammonium,  2  gram- 
mes (gr.  30);  sudorific  syrup  of  the  Codex,  300  grammes  (about  3  viss.). 
After  from  three  to  eight  days  the  scales  fall  off,  and  the  fresh  scales  be- 
come more  and  more  light  and  thin;  the  plaques  on  which  they  rest 
waste,  the  redness  is  extinguished;  and  at  last  the  cure  is  complete,  and 
often  permanent  ("  Annales  des  mal.  de  la  peau,"  oct.,  1851). 

M.  Guerard  has  revived  the  use  of  this  salt  in  acute  and  chronic  pul- 
mony  catarrh;  his  dose  is  1  or  2  grammes  (gr.  15 — 30)  in  a  draught. 


ALTERATIVES.  207 


Acetate  of  Ammonium. 


What  we  have  just  said  of  carbonate  of  ammonium  may  be  applied  to 
the  acetate.  But  we  cannot  pass  without  referring  to  what  Boerhaave, 
Cullen,  Selle  and  so  many  others  say  of  spiritus  Mindereri.  These  writers, 
and  our  own  contemporaries,  agree  in  ascribing  to  acetate  of  ammonium 
the  property  of  making  the  circulation,  the  secretions,  etc.,  more  active — 
a  property  which  it  shares  with  the  volaJ;ile  alkali  (Cullen:  "  Mat.  raed.,** 
t.  II.,  p.  366;  Selle,  "Obs.  de  med.,"p.  70).  As  regards  the  effect  upon  in- 
toxication (Mazuyer:  Gazette  de  sante,  nov.,  18^6),  migraine  {Ibid.),  and 
the  uterine  pains  which  accompany  menstruation,  it  has  no  special  prop- 
erty beyond  what  was  stated  under  ammonia.  But  the  acetate  of  am- 
monium has  lately  been  used  in  a  more  special  way  as  a  uterine  sedative. 
M.  Patin  has  reported  cases  which  tend  to  show  that  in  excessive  or  too 
frequent  menstruation,  or  uterine  hfemorrhages,  even  if  proceeding  from 
cancer,  this  remedy  diminishes  the  amount  and  frequency  of  the  discharge. 
Jt  is  then  given  in  the  amount  of  15  grammes  in  the  24  hours,  in  4  doses. 
The  same  physician  says  that  acetate  of  ammonia  has  often  succeeded  in 
his  hands  with  cases  of  difficult  and  painful  menstruation,  causing  the 
pain  to  cease  and  assisting  the  flow.  From  50  to  75  drops  may  be  given, 
divided  into  two  doses  and  mixed  with  a  glass  of  sweetened  water.  As 
soon  as  the  pains  and  disturbances  of  the  menstrual  period  appear,  the 
first  dose  is  given,  and  the  second,  if  necessary,  half  an  hour  later.  The 
amount  may  be  increased  according  to  the  severity  of  the  symptoms. 

He  also  reports  a  case  of  nymphomania  very  beneficially  treated  by  this 
remedy.  He  adds  the  inference,  that  acetate  of  ammonium  might  be 
very  useful  to  women  disposed  to  abortion  owing  to  determinations  of 
blood  to  the  uterus;  in  inflammations  of  the  uterus  and  ovaries,  and  in 
organic  lesions  of  the  same  parts  [Arch.  gen.  de  med.,  t.  XVIII.,  p.  317). 


Muriate  of  Ammois^ium. 

This  compound  has  no  special  virtue  distinct  from  that  of  the  others, 
as  may  be  seen  by  referring  to  Frederick  Hoffmann's  and  Arnold's  remarks 
on  its  influence  on  the  pulmonary  secretion  {Journal  complenietitaire,  t. 
XXVI.,  p.  300),  Kortunn's  and  Kuntzmann's  on  its  efficacy  in  rheuma- 
tism, etc.  We  shall  only  say  that  it  was  formerly  much  used  in  the  treat- 
ment of  intermittent  fevers  (Stoll),  but  usually  in  conjunction  with  cin- 
chona or  some  bitter. 

Nevertheless,  we  will  not  omit  the  use  made  of  it  by  Dr.  Fischer  in 
spasmodic  dysphagia.  He  gives  a  dose  of  125  centigrammes  (gr.  20) 
every  two  hours,  and  in  the  case  reported  by  him  it  was  continued  for 
eleven  weeks  (Arch.  gen.  de  med.,  t.  IL,  p.  118). 


208  THERAPEUTICS. 

Uronchitis, — Muriate  of  ammonia  has  a  very  liigh  reputation  in  Ger- 
many as  a  resolvent  in  chronic  bronchitis. 

Dr.  Delvaux,  of  Brussels,  says  that  he  has  found  it  very  useful  in  the 
dose  of  from  1  to  3  grammes  (gr.  15 — 45)  in  the  24  hours.  It  usually 
causes  a  great  sweating,  and  abundant  urine;  while  the  dyspncea  dimin- 
ishes, the  cough  becomes  less  fatiguing,  the  expectoration  easier  and  less 
abundant,  and  the  appetite  soon  reappears  (Journal  de  Bruxellea,  1854). 

M.  Marotte  speaks  well  of  its  effects  when  substituted  for  sulphate  of 
quinia  in  catarrhal  affections.     He  sums  up  his  results  as  follows: 

In  tlie  immense  majority  of  cases,  catarrhal  affections  affect  a  period- 
icity, taking  the  type  of  continued  remittents  or  intermittents,  quoti- 
dians, double  tertians  or  hemitrits.  This  has  been  known  from  their 
earliest  history,  and  has  no  novelty.  Nor  is  there  anything  new  in  the 
comparison  which  has  been  made  with  paludal  diseases. 

The  observation  of  the  causes  under  which  they  develop  is  sufficient 
to  prevent  confounding  them  with  the  latter.  These  special  causes  ex- 
plain wh}^  catarrhal  affections,  although  usually  controlled  by  cinchona, 
and  especially  by  sulphate  of  quinia,  on  account  of  their  periodicity, 
are  not  so  absolutely  nor  so  easily  controlled  by  it  as  affections  of  palu- 
dal origin.  They  may  give  to  catarrhal  affections  a  character  of  tenacity 
and  fixity  which  sometimes  makes  their  course  continuous,  and  resistant 
to  quinia,  even  when  they  seem  to  be  periodic.  This  is  fully  proved  by 
the  history  of  "medical  constitutions"  \i.e.  epidemic  conditions]  and  of 
general  epidemics. 

There  is  no  uniform  specific  treatment  for  catarrhal  affections;  they 
are  cured  by  obeying  the  indications  as  they  arise. 

The  present  epidemic  (18G7)  proves  that  catarrhal  affections  may  be 
made  less  tractable,  or  wholly  intractable,  to  sulphate  of  quinia,  by  an 
inflammatory  erethism,  which  doubtless  originates  from  the  general  pre- 
ponderance of  cold  in  the  midst  of  other  conditions  suitable  to  engender  it. 

Whatever  may  be  the  value  of  this  morbid  determination  and  of  this 
indication  for  sal  ammoniac,  and  whatever  the  results  of  further  observa- 
tion, it  follows  from  facts  observed  in  the  present  state  of  constitutions, 
that  muriate  of  ammonium  may  become  a  useful  substitute  for  sulphate 
of  quinia  in  catarrhal  affections.     (Academie  de  medecine,  avril,  1867). 

Senile  gangrene. — A  woman  aged  eighty-three  was  suddenly  seized 
■with  intolerable  pain  in  the  right  foot;  eighty -four  hours  later,  there 
was  a  general  blue-blackish  tint,  stopping  at  the  tibio-tarsal  joint,  where 
a  red  stripe  indicated  the  demarcation.  The  foot  was  perfectly  cold. 
Dr.  Gru  at  first  used  preparations  of  opium  in  enormous  doses,  but  the 
pains  continued  and  the  patient  seemed  in  despair.  He  then  put  250 
grammes  (  ^  viii.)  of  muriate  of  ammonium  in  a  foot-bath  reaching  to  the 
malleoli,  and  plunged  the  affected  foot  in  it.  In  two  hours  there  was 
considerable  relief.  Tlie  bath  was  then  replaced  by  fomentations  with 
the  same  solution,  and  the  patient  insisted  on  their  retention,  for,  as  often 
as  they  were  taken  off,  the  pain  reappeared  directly.     The  normal  warmth 


ALTERATIVES.  209 

and  color  soon  returned  under  this  influence,  the  nail  of  the  second  toe 
fell  off,  and  a  small  sore  was  formed  which  healed  in  three  weeks. 

A  year  later,  the  same  precursory  signs  appeared  in  the  same  foot. 
This  time,  muriate  of  ammonium  was  used  at  once,  and  its  sedative  prop- 
erties were  felt  immediately.  A  blackish  blister  appeared  on  the  outer 
border  of  the  foot,  covering  a  gangrenous  patch  which  fell  off,  and  the 
sore  healed  in  twenty-one  days.  No  further  trouble  of  the  sort  has  since 
occurred. 

This  action  has  never  before  been  mentioned;  let  us  hope  that  it  will 
be  confirmed  by  fresh  cases  {liulletm  medical  de  VAisne  and  Gazette  des 
hopitaux,  15  juin,  1867). 

Articular  rheumatism. — M.  Dujardin-Beaumetz,  having  sought  to  in- 
troduce the  hydrochlorate  of  trimethylamin  in  the  treatment  of  this  dis- 
ease, desired  to  see  if  the  muriate  of  ammonium,  which  closely  resembles 
it  in  chemical  composition,  had  similar  properties.  Sis  experiments  on 
the  guinea-pig,  rabbit,  and  frog,  showed  him  that  muriate  of  ammonium  in- 
jected into  the  subcutaneous  cellular  tissue  of  these  animals  produced  con- 
vulsive shocks  and  speedy  death;  the  muriate  of  trimethylamin  appearing 
much  less  poisonous.  These  experiments  are  not  very  applicable  to  ther- 
apeutics; they  may  serve  to  warn  physicians  of  the  danger  of  such  injec- 
tions, but  have  no  bearing  upon  the  administration  of  the  salt  by  the 
mouth;  in  fact,  a  dose  of  ten  grammes  (  3  iiss.)  of  the  salt  of  ammonia 
thus  given  has  produced  no  such  result  (Societe  de  therapeutique,  14mai, 
1873). 

M.  Martineau  has  used  muriate  of  ammonium  in  the  dose  of  ^  gramme 
daily  in  solution  in  a  julep,  for  cases  of  acute  articular  rheumatism.  The 
14  patients  thus  treated  seemed  to  him  to  recover  as  quickly  as  with  muri- 
ate of  trimethylamin.  M.  Delioux  de  Savignac  objects  to  these  optimis- 
tic conclusions,  that  half  a  gramme  (gr.  8)  is  a  very  small  dose  of  a  drug 
which  is  constantly  given  in  doses  of  60  grains  and  upwards.  It  is  to  be 
feared  that  the  real  result  is  not  so  favorable  as  M.  Martineau  seems  to 
think. 

Phosphate  of  Ammonium. 

This  salt  has  been  recommended  by  Buckler,  of  Baltimore,  as  very 
efficacious  in  gout,  rheumatism,  and  all  acute  or  chronic  diseases  depend- 
ing on  the  uric  acid  diathesis.  MM.  Edwards,  and  Mattel  of  Bastia,  sup- 
port this  opinion.  M.  Delioux  de  Savignac,  "Diet,  encyclopedique,"  art. 
Ammoniaque,  says  that  in  his  experience,  in  acute  articular  rheumatism 
treated  with  this  remedy,  the  urine  became  limpid  and  ceased  to  deposit 
uric  acid.  The  salt  has  been  given  in  the  dose  of  from  2  to  16  and  even 
20  grammes  (  3  ss. —  3  v.)  in  diabetes  mellitus  (Bouchardat). 

Valerianate  of  ammonia. — This  is  recommended  byPierlot;  and  Mo- 
reau  of  Tours,  and  Mesnel  consider  that  it  fills  a  certain  place  in  neuro- 
ses.    Dose  4  grammes  (  3  i-)  per  diem  in  liquid. 
14 


210  THERAPEFTICS. 


Chloride  of  Sodium. 

Diabetes. — Nasse  proved  that  the  blood  in  glycosuria  contains  less  salt 
than  normal  blood,  and  Thierfelden  and  Uhle,  that  the  urine  contains  an 
excess;  for  this  reason,  sea-salt  has  been  given,  in  the  hope  of  repairing 
the  losses  which  the  system  experiences,  if  not  of  curing  the  disease. 
This  was  done  in  1842  by  Martin  Solon,  then  physician  at  the  hospital 
Beaujon;  but  his  results  were  incoficlusive.  Coutant  ("These  de  Paris," 
1844)  and  Bouchardat  (•'  Momoires  de  I'academie  de  medecine,"  1851,  p. 
190)  repeated  the  trial;  the  latter  recommended  salted  meats  to  diabetic 
patients,  but  the  effect  of  the  meat  was  transitory,  and  was  limited  to  a 
diminution  of  the  thirst. 

Phthisis. — M.  Amedee  Latour  having  heard  from  a  keeper  of  monkeys 
that  he  preserved  his  beasts  from  having  phthisis  by  giving  them  sea-salt, 
made  the  experiment  in  his  own  practice,  and  published  two  memoires,  in 
1857  and  1859  {Union  rnedicale).  In  his  second  paper  his  views  had 
greatly  changed,  for  he  no  longer  gave  chloride  of  sodium,  but  the  milk 
of  a  goat  which  had  been  fed  with  salt;  this  increased  the  appetite  and 
lessened  the  sweats. 

We  believe  that  chloride  of  sodium  in  such  cases  is  a  more  powerful 
reconstituent  than  iron  or  iodine.  It  has  no  action  on  the  respiratory 
system,  but  it  aids  nutrition,  that  is,  assimilation.  For  this  reason  we 
advise  phthisical  patients  to  salt  their  food,  especially  their  meat,  while 
eating  it. 

Paludal  intoxication. — In  1841  chloride  of  sodium  was  recommended 
as  a  febrifuge  by  Piorry  (Academic  de  medecine)  and  Gintrac  p6re,  of 
Bordeaux,  and  in  1851  by  Bruys,  of  Bruges. 

To  give  value  to  any  trial,  it  should  be  made  in  a  fever  district.  Dr. 
Lariviere  used  it  at  Batna  (  Union  rnedicale,  aodt,  1851),  where  he  gave 
it  to  52  persons;  he  concludes  that  salt  had  a  certain  action  on  his  pa- 
tients; that  he  had  cured  the  accesses  in  some,  and  in  others  had  restored 
the  appetite  and  removed  the  paludal  anaemia  and  cachexia.  It  is  then 
inferior  to  sulphate  of  quinine,  but  may  in  part  take  the  place  of  the 
latter  when  wanting.  This  occurred  to  Dr.  Pioch,  when  in  1870  he  re- 
ceived in  the  camp  at  Sathonay  some  soldiers  suffering  with  African 
fever;  having  no  sulphate  of  quinia,  he  gave  chloride  of  sodium  in  the 
dose  of  10  grammes  in  half  a  glass  of  liquid  twice  a  day.  When  increased 
be^'ond  this  quantity  the  medicine  purged,  and  had  to  be  stopped. 

Cholera. — In  the  epidemic  of  1831  Dr.  Ochel  believed  that  he  found 
sea-salt  useful  in  cholera;  but  Recamier,  in  1832,  Stevens,  in  1849,  and 
Aran,  in  1843,  used  the  same,  w'ith  only  doubtful  results. 

More  recently,  M.  Lorain  and  Dujardin-Beaumetz  have  repeated  the 
trial,  by  injecting  salt  into  the  veins;  under  the  influence  of  this  active 
treatment  the  patients,  even  in  the  algid  stage,  have  been  seen  to  grow 
warm,  to  cease  vomiting,  and  even  to  begin  to  eat. 


J 


ALTERATIVES.  211 

Intestinal  tcorms. — All  who  have  had  to  treat  this  trouble  have  found 
it  somewhat  difficult.  We  would  ask  attention  to  this  harmless,  cheap 
and  accessible  remedy,  which  has  been  used  by  M.  Lecoeur  of  Caen,  in 
the  form  of  an  injection.  He  gives  half  a  gramme  (gr,  8),  and  finds 
that  one  injection  almost  always  kills  the  oxyures,  and  more  than  two 
have  never  been  needed. 


External  Action^  of  Chloride  of  Sodium. 

All  who  have  written  on  warm  sea-baths,  as  Gaudet  of  Dieppe,  Roccas 
of  Trouville,  Joubert  of  Villers,  etc.,  confirm  our  account  regarding  the 
physiological  action  of  this  salt.  The  following  is  a  statement  of  the  re- 
sults obtained  by  Dr.  Bergeron  at  the  hospital  of  Berk-sur-mer  in  the 
Pas-de-Calais,  from  July,  1861,  the  date  of  his  installation,  to  Dec.  31,  1865: 

During  this  period  380  scrofulous  or  rachitic  children  were  sent  to 
Berk  by  the  hospitals  of  I'Enfant-Jesus  and  Sainte-Eugenie,  and  by  the 
Service  des  Enfants  Assistes,  from  Paris  and  from  the  arrondissements 
near  that  of  Montreuil.  The  average  period  of  residence  of  these  chil- 
dren was  nine  months.  Some,  who  had  a  mild  form  of  scrofula,  remained 
at  Berk  only  six  or  eight  weeks;  others,  who  presented  a  deep  and  ob- 
stinate form,  the  cure  of  which  required  a  real  transformation  of  the  or- 
ganism, passed  more  than  a  year  there. 

In  the  earlier  part  of  this  period,  says  M.  Bergeron,  for  want  of  expe- 
rience to  guide  in  a  selection,  all  the  forms  of  scrofula  were  sent,  from 
scrofulidje  of  the  skin  and  mucous  membranes  to  the  most  profound 
caries,  and  even  necroses  consecutive  to  suppurative  periostitis;  but  by 
degrees  it  was  found  that  while  all  the  children  derived  the  greatest  bene- 
fit from  the  vivifying  effects  of  the  baths  and  the  air,  there  were  certain 
local  lesions  which  were  but  slightly  affected,  or  even  were  made  worse, 
while  others  were  absolutely  obstinate  to  this  influence.  For  instance, 
chronic  blepharitis,  and,  in  general,  diseases  of  the  eye  and  eruptions  of 
simple  and  impetiginous  eczema,  were  rarely  improved,  and  usually  made 
worse,  while  otorrhcea  without  osseous  lesion,  extensive  caries,  and  pro- 
found necroses,  remain  stationary  indefinitely.  From  that  time  the  in- 
dications were  clearly  traced.  For  the  last  three  years,  the  cases  pre- 
ferred were  those  of  enlarged  glands,  cold  abscesses,  scrofulous  gummata, 
white  swelling,  and  rachitis. 

Of  380  children  sent  to  Berk,  118  had  chronic  adenitis,  chiefly  of  the 
cervical  and  submaxillary  regions;  usually  consecutive,  either  to  eruptions 
of  the  face  or  scalp,  which  mostly  disappeared  at  the  moment  of  departure 
for  the  sea,  or  else  to  old  deep  lesions  of  the  limbs  or  trunk.  These  118 
presented  all  the  varieties  of  chronic  adenitis,  from  recent  simple  engorge- 
ment without  induration  to  glandular  masses  infiltrated  with  tubercle, 
with  or  without  ulcers  of  the  skin.  Scrofulous  adenitis  is  notoriously 
an  obstinate  complaint  under  any  treatment.     Of  these  children  85  were 


212  THEE  APE  UTICS. 

completely  cured,  excepting  one  who  succumbed  to  a  cachectic  condition 
which  was  not  arrested  by  the  influence  of  the  sea;  while  all  the  rest 
improved,  and  would  no  doubt  have  greatly  increased  the  number  of 
cures  if  they  had  not  been  sent  back  prematurely  for  divers  reasons. 

The  saline  air  has  not  the  marvellous  power  of  dissolving  cretaceous 
indurations  and  producing  immediate  cicatrization  of  scrofulous  ulcers. 
M.  Bergeron  does  not  hold  such  a  view;  but  it  seemed  to  him  that  simple 
indurations,  however  old  and  indolent,  recovered  under  this  influence 
more  rapidly  than  when  treated  by  the  usual  drugs,  and  that  cervical  or 
submaxillary  glands  which  were  completely  transformed  into  tuberculous 
nodules  had  sometimes  disappeared,  after  a  long  period,  without  leaving 
any  traces  beyond  a  movable  indolent  induration. 

"  I  have  seen  several  such  cases,"  says  he,  "among  the  patients  at  Berk; 
and  while  these  facts  are  not  new,  they  deserve  to  be  noted  as  showing 
how  great  benefit  may  be  derived  from  saline  waters  in  the  treatment  of 
certain  cases  of  tuberculous  adenitis,  which  are  so  seated  as  to  become 
far  more  dangerous  than  those  seated  subcutaneously;  I  refer  to  mesen- 
teric and  tracheo-bronchial  adenitis." 

We  give  some  of  the  results  in  the  worst  forms  of  scrofula,  particularly 
of  the  long  bones  and  the  peri-articular  soft  tissues. 

There  were  admitted  to  the  Berk  hospital  85  children  with  white  swell- 
ing, most  of  them  in  the  way  of  recovery,  while  others  were  in  a  station- 
ary condition,  in  spite  of  the  most  rational  treatment,  and  others  were  in 
a  desperate  state,  as  regards  the  preservation  of  the  limb.  Of  these  85 
patients,  4  died,  3  from  excessive  suppuration,  and  1  from  a  complication 
of  visceral  tuberculosis;  13  left  Berk  without  sensible  improvement.  Of 
the  18  who  returned  to  Paris  incompletely  cured,  but  so  far  improved  that 
a  cure  could  confidently  be  expected,  there  were  several  whose  cases  were 
very  interesting.  "  Coming  to  the  sea-shore  in  a  pitiable  condition,  from 
general  exhaustion  and  grave  local  disease,  little  by  little,  under  the  in- 
fluence of  a  revivifying  atmosphere,  these  unhappy  beings  felt  their  ap- 
petite returning,  their  strength  renewed;  the  swollen  joints  soon  began 
to  lessen  in  bulk,  the  suppuration  became  less,  and  most  of  the  fis- 
tulas healed;  sometimes  the  joints  even  recovered  a  part  of  their  mo- 
bility." 

Of  38  patients  with  Pott's  curvature,  12  returned  completely  cured;  the 
iliac  abscesses  were  absorbed,  the  general  health  was  perfect,  and  the  walk 
was  as  free  and  easy  as  the  curvature  of  the  spine  permitted.  Two  chil- 
dren sent  back  as  cured  returned  after  five  and  seven  months  with  new 
collections  of  pus.  Seventeen  others  who,  for  divers  reasons,  left  the  place 
prematurely,  were  improved  in  general  health,  but  not  cured,  some  of  them 
with  a  commencement  of  absorption  in  the  "  abces  par  congestion."  Six 
went  away  without  any  benefit,  and  three  died  from  excessive  suppura- 
tion. 

Of  the  entire  number  of  380  cases,  284  recovered,  or  74  per  cent.;  93 
were  improved,  or  24  per  cent.;  18  died,  or  4.7  per  cent.,  and  in  35  the 


ALTERATIVES.  213. 

effects  were  null,  9  per  cent.  These  figures  place  the  power  of  the  sea- 
treatment  beyond  a  doubt. 

Such  are  the  chief  indications  for  sea-baths;  for  the  rest,  we  shall 
note  here  only  those  diseases  which  are  not  benefited  by  cold  sea-baths, 
but  may  be  improved  by  warm  sea-baths  and  water  containing  common 
salt. 

Lymphatism. — Scrofula. — liachittsm. — Children  under  three  years  of 
age  cannot  take  surf-baths  without  danger,  while  warm  sea-bathing  does 
them  the  greatest  good,  and  assists  the  action  of  the  sand-bath  which 
they  take  all  day  in  playing  on  the  beach. 

Among  the  scrofulous  affections,  those  which  are  most  benefited  by 
water  charged  with  chloride  of  sodium  are  the  chronic  adenopathies,  ar- 
ticular and  osseous  lesions,  and  inflammations  of  the  ocular,  palpebral, 
and  nasal  mucous  membranes,  and  scrofulidae  of  the  skin.  These  affec- 
tions are  advantageously  treated  by  warm  sea-baths  at  the  establishments 
of  Salies,  Bourbonne,  Balaruc,  Salins  (Jura),  Lamotte,  and  Kreuznach. 

Atony. — Senile  debility,  and  that  due  to  any  physical  exhaustion,  are 
greatly  improved  by  baths  of  warm  sea- water;  and  the  same  is  the  case 
with  the  debility  of  pregnant  women  and  of  those  who  are  fatigued  by 
successive  pregnancies  or  nursing. 

Uterine  affections. — Nervous  or  inflammatory  hysteralgia  is  relieved  in 
a  remarkable  way  by  baths  of  warm  salt  w^ater  like  those  of  Bourbon- 
I'Archamljault. 

JRheuinatism. — Patients  subject  to  the  rheumatic  diathesis  and  who 
suffer  from  atonic  rheumatism,  or  from  catarrhal  susceptibility,  obtain 
from  salt  water  a  power  of  resistance  which  enables  them  for  a  time  to 
avoid  these  complaints.  This  property  of  the  chloride  of  sodium  waters 
is  best  found  in  those  of  Salies  and  of  Bourbon-l'Archambault.  At  Bour- 
bonne very  good  effects  have  been  noticed  in  dry  arthritis. 

Paralysis. — The  stimulant  action  of  chloride  of  sodium  waters  on  the 
periphery,  aided  by  their  laxative  action,  has  helped  hemiplegic  patients 
in  recovering  movement,  after  apoplexy  or  paraplegia.  Those  which 
have  the  best  reputation  in  these  cases  are  the  waters  of  Bourbonne, 
Bourbon-l'Archambault  and  Balaruc.  The  same  is  true  of  muscular  and 
articular  stiffness,  following  fractures  and  wounds  in  war. 


Alterative  Treatment  in  General. 

There  are  certain  agents  of  the  materia  medica  which  have  only  a  tran- 
sient action  upon  the  system;  the  modification  seems  to  have  affected  the 
nervous  system  only;  a  few  moments,  hours,  or  days  efface  all  traces  of 
the  passage  of  the  remedy.  In  this  category  we  place  the  irritants  and 
the  escharotics,  which,  while  causing  an  active  or  local  disturbance  as  for- 
cible, do  not  strike  to  the  inward  parts  of  the  system,  and  limit  their 
action  to  a  short  range. 


214  THERAPEUTICS. 

Others  there  are  which  bestow  on  the  organic  elements  something 
which  remains,  which  survives  the  original  impression;  it  may  be  a  con- 
stituent element  or  an  improved  functional  aptitude,  and  then  the  remedy 
is  called  an  analeptic  or  reconstituent;  it  may  be  that  the  blood  and  the 
humors  are  altered  in  kind,  are  made  less  fit  to  aid  in  the  act  of  nutrition 
and  to  furnish  materials  for  acute  or  chronic  phlegmasia^;  or  act  by  pre- 
venting the  generation  of  secondary  accidental  products;  tlie  latter  class 
are  called  alteratives. 

In  the  case  of  diseases  which  hardly  modify  the  system,  or  which 
occupy  an  organ  of  minor  importance,  it  is  easy  to  see  that  a  superficial 
treatment,  if  we  may  so  speak,  is  sufficient  to  cure;  but  when  the  system 
is  deeply  affected,  when  an  extremely  important  organ  is  touched,  or  a 
great  number  of  local  lesions  are  equivalent  to  one  lesion  of  great  extent; 
or  when  a  disease,  chronic  in  its  progress  and  its  form,  rebellious  and 
tenacious  in  its  nature,  has  become  rooted  in  the  system,  a  more  energetic 
resistance  must  be  made  to  the  more  vigorous  atack;  and  then  it  is  that 
we  have  to  use  agents  which  cause  deep  modifications. 

At  the  head  of  alterative  remedies  we  must  place  bloodletting.  This 
practice,  which  we  shall  study  especially  under  antiphlogistic  treatment, 
not  only  despoils  the  vascular  system,  and  in  consequence  all  the  tissues 
to  which  the  latter  carries  life,  but  it  changes  the  intimate  composition  of 
the  blood,  as  we  shall  show  later.  But  though  often  applicable  in  acute 
conditions,  it  cannot  be  denied  that  this  remedy  is  usually  inadmissible  in 
the  chronic  state;  frequent  and  long-continued  bleedings  would  com- 
promise the  general  health  too  much.  We  have  then  to  recur  to  agents 
which  modify  the  blood  without  entirely  destroying  the  reparative  ele- 
ments it  contains.     Such  agents  are  the  alteratives. 

The  alkalines  occupy  a  place  among  these  remedies  which  is  certainly 
as  important  as  that  of  mercury,  to  which,  as  to  iodine  and  arsenic,  we 
have  given  much  attention;  we  must  here  devote  a  few  lines  to  their 
study. 

Such  is  the  importance  of  the  alkalines,  that  they  may  be  said  to  be  as 
necessary  to  the  accomplishment  of  certain  functions  as  oxygen  is  to 
respiration. 

If,  now,  it  be  necessary  to  define  the  mode  of  action  of  these  agents, 
and  their  special  role  in  the  economy,  we  should  say  that  our  modern 
physiologists  consider  the  alkalines  as  indispensable  to  the  phenomena  of 
endosmosis,  combustion,  digestion,  and  the  secretions. 

Thus,  they  are  believed  to  contribute  to  maintain  in  the  blood  that 
degree  of  viscosity  which  is  necessary  to  render  it  fit  for  endosmosis, 
exosmosis,  and  the  various  compositions  and  decompositions  which  con- 
stitute organic  life.  They  enable  the  saccharine  and  amyloid  foods  to 
unite  with  oxygen,  and  to  assist  in  the  functions  of  respiration  and  calor- 
ification. They  make  the  elements  of  the  bile  fluid,  prevent  them  from 
inspissating  and  forming  concretions  or  calculi.  Let  us  add  that  they 
emulsionize  and  saponify  the  fatty  matters,  maintain  the  intestinal  diges- 


ALTERATIVES.  215 

tion,  facilitate  secretion,  and  thus  actively  co-operate  in  all  the  acts  of 
nutrition  and  assimilation. 

Whatever  may  be  the  value  of  these  physiological  interpretations 
drawn  from  chemistry,  it  is  very  certain  that  the  alkalines  have  an  im- 
mense influence  upon  the  system,  by  the  same  title  with  the  acids;  and 
'it  could  not  be  otherwise.  The  blood  is  naturally  alkaline  in  a  certain 
fixed  degree,  whereby  it  is  made  able  to  distribute  special  chemical 
qualities  to  the  various  secretions.  Of  these,  some  are  slightly  alkaline,  as 
the  saliva  and  pancreatic  juice;  others  are  so  to  a  very  high  degree,  as  the 
bile.  Others  are  very  acid,  as  the  urine,  sweat,  and  gastric  juice.  If  the 
blood  is  rendered  more  alkaline  by  the  use  of  alkalis,  there  will  come  at 
last  a  special  condition  of  the  blood,  a  new  state  of  the  secretions.  Those 
which  are  naturally  alkaline  or  neutral  will  increase  in  alkalinity;  those 
which  are  acid  will  become  less  so,  or  will  be  neutral  or  alkaline.  These 
are  necessary  chemical  effects.  If  the  presence  of  acids  is  a  necessary 
condition  of  the  stomach-digestion,  it  cannot  be  a  matter  of  indiffer- 
ence to  neutralize  the  acids.  Furthermore,  chemists  say  that  a  correct 
proportion  of  alkalis  in  the  blood  enables  this  liquid  to  consume  in  due 
proportion  the  carbonaceous  elements  absorbed  in  the  act  of  digestion, 
such  as  sugar,  fats,  alcohol.  An  incomplete  combustion  would  doubtless 
produce  the  evils  of  which  we  shall  presently  speak;  but  excessive  or  too 
rapid  combustion  is  equally  dangerous,  as  causing  important  changes 
in  the  composition  of  the  blood,  and  therefore  in  the  texture  of  the 
organs. 

If  this  be  true,  the  giving  of  alkalines,  in  health  or  in  sickness,  can 
never  be  a  matter  of  indifference.  If  taken  without  good  grounds  for  a 
short  time  only,  they  do  but  momentary  harm ;  if  taken  largely  and  long, 
they  cause  a  deplorable  cachexia  and  emaciation. 

The  influence  of  alkalis  on  the  composition  of  the  blood  was  admirably 
stated  by  the  ancients.  They  had  seen  that  this  nourishing  fluid  became 
paler  and  more  fluid;  and  that  at  last  a  state  of  cachexia  was  established, 
characterized  by  pallor,  general  puffiness  and  passive  hfemorrhages;  ema- 
ciation, often  irreparable,  followed.  The  excessive  use  which  has  lately 
been  made  of  the  waters  of  Vichy,  Carlsbad,  and  Pougues  in  treating 
gout,  has  furnished  illustrations  of  this  point;  we  do  not  fear  to  say  that 
the  abuse  of  alkalines  has  caused  more  harm  than  the  abuse  of  iodine. 

When  in  an  acute  disease  we  wish  to  produce  in  the  crasis  of  the 
blood  a  rapid  change  analogous  to  that  caused  by  bleeding,  we  use  mer- 
curials, especially  calomel,  by  Law's  method,  as  described  above;  but 
when  there  is  a  chronic  disease  of  the  liver  or  a  diathetic  disease  with 
a  real  or  supposed  predominance  of  acids  in  the  secretions,  such  as  gout, 
we  must  use  the  alkalines — taking  care  not  to  pass  beyond  our  aim. 

The  attacks  of  gout  are  certainly  lightened  by  using  the  waters  of 
Pougues,  Vichj'',  or  Carlsbad  with  perseverance;  the  formation  of  uric  acid 
gravel  in  the  kidneys  may  be  prevented  with  still  more  certainty  by  the 
same  remedies;  but  to  extinguish  the  symptoms  of  gout  is  not  to  cure 


216  THEEAPEUTICS. 

gout,  any  more  than  driving  away  cutaneous  eruptions  by  local  remedies 
is  curing  syphilis.  The  diathesis  is  so  persistent  that  the  attacks  will  re- 
turn unless  the  patient  places  himself  under  special  hygienic  influences. 
It  is  doing  a  great  deal  to  make  the  attacks  less  frequent  and  acute,  but 
if  we  undertake  to  destroy  the  diathesis,  as  certain  ignorant  physicians 
profess,  we  undermine  the  foundations  of  the  constitution,  and  the  abuse 
of  alkalines  brings  on  the  cachexia  of  which  we  lately  spoke,  a  morbid 
condition  much  more  grave  and  incurable  than  gout  and  gravel. 

The  liver  swells  and  becomes  fatty  in  animals  fed  on  highly  carbonized 
food  and  kept  inactive.  We  know  that  exercise  is  one  of  the  best  means 
of  assisting  the  destruction  of  the  carbonized  principles,  especially  fat; 
we  know  also  (and  here  the  chemical  theory  agrees  with  clinical  experi- 
ence) that  the  consumption  of  alkalies  and  the  consequent  alkalization  of 
the  blood  usually  hastens  this  destruction  and  supplements  an  inactive 
respiration.  It  is  well  established  that  the  alkalines  diminish  the  coagu- 
lability of  the  blood;  and  it  would  seem,  though  we  by  no  means  affirm 
it,  that  in  attacking  the  albumin  and  fibrin  directly  they  acquired  the 
power  of  dissolving  the  two  chief  basal  elements  of  most  chronic  engorge- 
ments. This  property  is  most  remarkable  in  the  case  of  hepatic  engorge- 
ments, vulgarly  called  obstructions.  Theory,  then,  would  have  led  to  the 
use  of  alkalines  in  chronic  disease  of  the  liver,  even  if  practice  had  not 
decided  hundreds  of  years  ago. 

But  the  alkalines  must  not  be  abused.  Phj^sicians  do  not  sutBciently 
bear  in  mind  that  the  inherent  properties  of  the  living  tissues  enable  them 
to  resolve  engorgements  when  the  first  impulse  has  once  been  given.  In 
bleedino-  for  pneumonia,  we  suppose  that  we  are  removing  the  excess  of 
blood  from  the  lung:  this  idea  cannot  be  entertained  by  any  one  who  has 
any  notion  of  physiology ;  it  is  rather  that,  after  the  bleeding,  an  obstacle 
to  the  performance  of  the  nutritive  functions  of  the  pulmonary  tissue  is 
removed,  and  resolution  is  effected  by  virtue  of  properties  inherent  in  the 
tissue  of  the  lungs,  without  subsequent  medical  interference. 

The  obstacle  which  is  sometimes  removed  in  one  instant  in  acute  dis- 
ease can  only  be  destroyed  slowly  in  chronic  disease;  but  when  removed, 
the  properties  of  the  tissue  resume  their  role,  and  the  physician  should  be 
simply  an  attentive  and  intelligent  spectator. 

This  should  enforce  the  precept  which  we  just  gave,  to  wit:  that  in 
treating  chronic  disease  of  the  liver  we  must  stop  the  alkalines  as  soon  as 
resolution  of  the  engorgement  fairly  begins;  not  pursuing  the  disease, 
which  is  bound  to  get  well  without  us. 

A  neglect  of  the  natural  powers  of  the  tissues  is  the  reason  why  so 
many  physicians  use  alkalines  too  long  in  complaints  of  the  liver.  A  per- 
son feels  a  little  better  on  returning  from  Vichy,  Pougues,  or  Carlsbad;  his 
health  is  confirmed  during  the  winter.  He  thinks  it  necessary,  in  order 
to  prevent  relapses,  to  take  the  waters  several  months,  for  some  years  in 
succession;  but  instead  of  the  former  benefits,  he  gains  only  discomfort, 
and  sometimes  serious  trouble,  which  he  ought  to  ascribe,  not  to  the  ob- 


ALTEK  ATIVES.  217 

stinacy  of  his  disease,  but  to  his  blind  persistence  beyond  the  point  of 
usefulness. 

How  is  it  that  physicians  do  not  see  that  a  remedy  which  is  powerful 
to  cure  must  be  powerful  to  do  harm  ? 

The  alkalines  are  given  with  singular  levity.  A  month  or  two  of  the 
water  of  Vichy,  Carlsbad,  or  Pougues  is  prescribed  as  one  would  order  a 
ptisan  of  barley  or  borage;  but  is  it  of  so  little  consequence,  to  alter  at 
one  blow  all  the  secretions  of  the  body  ? 

Other  alterants  are  usually  handled  with  more  prudence;  mercury  is 
considered  a  serious  thing,  because  its  danger  is  understood  a  little  better. 
And  so  with  iodine. 

Yet,  how  many  physicians  in  constitutional  syphilis  give  mercury  with 
deplorable  persistency,  following  on  the  heels  of  every  symptom,  and 
never  thinking  the  disease  overcome  till  the  periostoses  are  entirely  gone, 
and  the  necrosed  portions  of  the  palatine  or  ethmoid  have  all  fallen! 

The  general  conception,  more  or  less  vague,  of  a  specific  is  that  it  goes 
directly  at  the  principle  of  a  disease,  and  neutralizes  it  directly  by  its 
own  force.  The  laws  of  the  organism  do  not  apply  to  it.  It  is  neither 
by  a  stimulant,  sedative,  cold,  hot,  dry,  moist  virtue,  nor  by  any  other 
particular  property,  that  it  acts  specifically;  but,  as  Galen  says,  by  its 
whole  substance.  Cinchona  cures  intermittent  fever,  not  because,  as  some 
say,  it  is  tonic — or  as  others  say,  sedative,  astringent,  and  mummifying, 
stomachic,  diaphoretic,  antispasmodic,  etc.  No;  between  the  cause  of 
intermittent  fevers  and  cinchona  there  exists  an  incompatibility  in  which 
the  disease  succumbs,  as  in  the  case  of  two  botanical  or  zoological  spe- 
cies which  cannot  live  together,  so  that  one  always  destroys  the  other. 
Mercury  does  not  cure  syphilis  because  it  is  acid  or  alkaline,  antiplastic 
as  is  now  said,  or  coagulant,  as  was  formerly  thought.  It  acts  on  this 
disease  as  blue  ointment  does  on  lice — it  kills  it.  The  organism  has  no 
chance  to  interpose  in  the  action  of  cinchona  or  mercury:  it  contains 
certain  entozoa,  which  the  drugs  poison,  and  that  is  all.  The  poison  acts 
by  affinity;  without  injuring  the  organism,  it  exterminates  the  parasite 
as  in  a  test-tube.  This  is  of  course  very  simple;  the  disease  is  not  so 
mysterious  as  had  been  supposed. 

We  beg  to  call  attention  to  one  point:  in  this  theory  the  disease  is  con- 
founded with  a  morbid  product.  It  is  compared  with  something  contained 
in  the  system,  as  the  worm  is  in  the  intestine,  or  mechanically  mingled  with 
the  blood,  or  extravasated  in  the  tissues.  This  is  the  interpretation  given 
by  humorism;  the  uselessness  of  the  organism  during  the  action  of  the 
specific  is  manifest.  Everything  occurs  in  it,  yet  without  its  action. 
Who  is  bold  enough  to  sustain  this  theory  ?  Professed  or  not,  expressed 
or  implicit,  it  is  nevertheless  that  of  the  immense  majority  of  physicians, 
and  almost  all  our  pathological  and  therapeutical  writings  presuppose  it. 
It  is  as  pregnant  with  dangers  as  Avith  errors. 

The  specific  remedies  have  no  other  general  method  of  action  than 
those  which  are  not  specific.     In  brief,  they  act  either  with  the  assist- 


218  THERAPEUTICS. 

ance  of  life  or  without  it.  To  its  acting  without  life  there  are  grave  ob- 
jections. 

Mixed  with  mercurial  preparations,  the  syphilitic  virus  is  most  posi- 
tively inoculable.  Taken  before  the  development  of  visible  syphilitic  le- 
sions, mercury  does  not  prevent  them.  This  might  excuse  us  from  finish- 
ing the  refutation.  Syphilitic  and  mercurial  symptoms  pursue  their  way 
together  in  the  same  person  without  influencing  each  other  at  all.  The 
mercurial  not  unfrequently  aggravate  the  syphilitic  symptoms,  adding 
their  own  characteristics  and  producing  a  mixed  affection,  a  syphilitico- 
mercurial  cachexia,  which  is  very  hard  to  cure.  Finally,  by  the  side  of 
persons  whom  mercury  cures  of  ordinary  syphilis  without  producing  any 
appreciable  mercurial  symptom,  there  are  others  in  whom  the  disease  pur- 
sues its  ravages  undisturbed.  Add  anotlier  very  common  case,  and  we 
have  all  that  are  possible — the  appearance  of  mercurial  accidents  simul- 
taneously with  the  disappearance  of  those  of  syphilis.  Considering  this 
diversity  of  the  relations  between  the  two  series  of  symptoms,  one  vene- 
real and  the  other  mercurial,  what  is  the  meaning  of  the  cases  in  which  a 
mercurial  modification,  whether  appreciable  or  not,  dispels  the  symptoms 
of  syphilis  ? 

Singular  contrast  !  Mercury  arouses  in  the  healthy  tissues  alterative, 
antiplastic,  exulcerant  actions;  and  in  tissues  devoured  by  syphilis,  plastic 
and  separative  actions.  What  was  the  cause  of  destruction  in  one  case  is 
the  cause  of  regeneration  in  the  other;  and  it  is  the  same  mode  of  irrita- 
tion that  produces  such  opposite  effects  !  How  can  these  contradictory 
properties  be  ascribed  to  one  modifying  agent,  if  its  scope  be  limited  to 
its  action  as  an  antidote,  which  neutralizes  a  poison  by  forming  with  it  a 
harmless  compound  ?  To  respond  by  ulceration  and  by  cicatrization  to 
the  same  influence  is  a  proof  of  capacity  for  two  opposite  effects.  They 
do  not  proceed  in  reality  from  the  mercury,  but  from  the  organism  as  im- 
pregnated with  the  virtue  of  mercury.  Our  body  then  contains  morbid 
properties  which  mercury  brings  to  activity  by  the  effect  of  certain  quali- 
ties which  belong  to  it  alone,  and  which  may  be  called  specific  qualities, 
if  we  do  not  attach  to  the  word  an  occult  and  reserved  sense,  but  which 
we  prefer  to  call  simply  mercurial.  Every  body  in  nature  has  properties 
which  none  other  possesses,  and  in  this  respect  mercury  forms  no  excep- 
tion. The  tonics  and  the  emollients,  water  and  wine,  are  in  this  respect 
as  incomprehensible  as  mercury. 

The  system  cures  syphilis  under  the  influence  of  mercury.  We  must 
keep  ourselves  within  this  idea.  Nitrate  of  silver  applied  to  a  chancre 
cures  it  perfectly:  shall  we  infer  that  it  is  a  specific  in  syphilis?  Who 
does  not  see  that  this  agent  merely  excites  a  morbid  vital  action  or  an 
irritation  which  is  different  and  less  injurious,  and  is  spontaneously  cured  ? 
If  mercury  be  the  counter-poison  of  syphilis,  why  does  it  not  always  neu- 
tralize it  ?  It  will  be  replied  that  it  does  this,  when  syphilis  is  free  from 
other  pathological  elements.  We  may  as  well  say,  with  Hunter — who 
was,  nevertheless,  an  exaggerated  partisan  of  mercury — that  mercury  is 


ALTERATIVES.  219 

the  antidote  or  specific  remedy  of  the  venereal  disease  considered  ab- 
stractly. And  yet,  spite  of  his  fanatic  attachment  to  mercury,  Hunter 
reg-arded  its  action  as  a  vitalist  would.  Our  present  object  is  simply  to 
apply  the  general  laws  of  all  medicines  to  the  specific  remedies,  which 
are  always  represented  as  more  mysterious  and  extraordinary  than  the 
others;  and  to  prove,  further,  that  their  exceptional  eflficacy  in  various 
diseases  depends  upon  certain  exceptional  peculiarities  in  the  diseases 
quite  as  much  as  on  the  intrinsic  power  of  the  remedy. 

The  organism,  excited  by  food,  draws  from  it  the  various  components 
of  the  body.  It  stands  in  the  same  relation  to  remedies,  educing  their 
properties,  developing  and  vivifying  them;  for  through  it  they  become 
alive,  or  life  itself  modified  in  various  ways.  It  assimilates  or  makes  sim- 
ilar to  itself  a  part  of  these  foreign  forces.  They  pass  into  it,  it  raises 
them  to  its  order  of  activity.  It  transfers  them,  not  by  juxtaposition, 
but  by  intussusception;  and  it  then  draws  the  remedial  action  from  itself, 
"ab  intus  suscipit."  A  living  mirror  of  the  properties  of  these  poisons,  one 
may  say  that  it  becomes  successively  opium,  mercury,  cinchona,  antimony, 
belladonna,  etc.  It  is,  if  we  choose,  opium,  mercury,  etc.,  in  a  more  ele- 
vated order  of  activity,  more  truly  representative  of  their  essential  prop- 
erties, which  live  for  a  moment  a  superior  life,  and  are  for  a  moment  in  a 
certain  sense  animalized.  There  are  neither  metaphors  nor  comparisons 
here,  but  the  most  absolute  physiological  rigor;  we  are  at  the  root  of  ther- 
apeutics. Vitalism  rescues  toxicology  from  the  lower  region  of  retorts 
and  alembics;  and,  without  breaking  with  tradition,  but  largely  supported 
by  it,  raises  materia  medica  to  the  dignity  of  physiology. 

The  specifics  and  their  type,  mercury,  can  claim  no  exception.  The 
healthy  organism  must  consent  to  its  physiological  action;  and  to  the 
latter,  the  syphilized  organism  must  consent.  There  is  no  more  chemical 
action  in  this  than  in  nutrition  or  conception,  and  we  may  say  in  full  strict- 
ness that,  in  order  that  mercury  shall  act,  the  syphilized  system  must 
conceive  the  properties  of  mercury,  just  as,  in  order  to  contract  syphilis, 
it  had  to  conceive  the  syphilitic  virus.  But  the  latter  acts  on  the  sys- 
tem more  profoundly  than  mercury,  for  it  is  a  product  of  the  system,  a 
more  intimate  morbid  poison  than  any  other.  Mercury  does  not  thus  af- 
fect the  system  in  its  essence;  it  modifies  the  nutrition  and  secretion  tran- 
sitorily, and  thereby  affects  the  deviations  in  their  functions  which  the 
venereal  poison  occasions.  But  these  symptoms  presuppose  invisible  roots 
to  the  malady.  Mercury,  a  body  not  homogeneous  to  our  own,  seems  un- 
able to  pursue  the  initial  living  cause  of  sypiiilis  thus  far — or,  if  it  does 
so,  it  seems  unable  to  identify  itself  with  the  system.  Mercury,  then,  at- 
tacks the  symptoms  and  not  the  principle.  But  what  a  specific,  even  from 
this  aspect  !  And  is  it  quite  true  that  it  cures  all  the  symptoms  so  won- 
derfully ?     Here,  perhaps,  we  touch  the  secret  of  mercury. 

Mercury  is  most  efficient  in  one  phase  of  the  venereal  disease,  that  of 
the  secondary  symptoms,  which  affect  chiefly  the  skin  and  mucous  mem- 
branes.    It  is  at  least  useless  in  the  primary  symptoms;  taken  then,  it  is 


220  THERAPEUTICS. 

not  proved  that  it  prevents  the  development  of  secondary  symptoms. 
Finally,  its  efficacy  diminishes  in  proportion  to  the  remoteness  of  the  pri- 
mary impregnation;  and  in  the  third  order  of  symptoms,  those  of  the 
deeper  organs,  bones,  the  weakly  vitalized  white  tissues,  its  therapeutic 
activity  is  so  weakened  that  it  loses  a  great  part  of  its  privilege  and 
yields  its  specific  virtue  to  iodine.  Let  us  mark  well,  that  in  the  period 
when  we  may  usually  do  without  mercury,  it  is  no  more  a  specific  than 
nitrate  of  silver  or  any  other  substitutive  modifier.  When  the  disease 
has  struck  deep  root,  and  is  hard  to  tear  out,  and  has  intimatelv  altered 
the  constitution,  mercury  is  of  hardly  any  more  value  than  in  other  non- 
venereal  affections  of  the  same  parts,  and  iodine  easily  contests  its  supe- 
riority. The  time  of  its  triumph  is  the  intermediate  period,  which,  of  all 
the  non-organic  affections  of  our  tissues,  is  the  most  mobile,  tlie  most  di- 
versified, the  most  modifiable,  the  most  alterable.  For  incurabilitv,  it 
cannot  be  compared  with  cancer,  tubercle,  etc.  Now,  mercury  is  the 
most  potent  of  alteratives.  How  do  we  know  that  its  specific  virtue  is 
not  due  to  this  alone  ?  Why  should  so  singular  an  anti-venereal  power 
fail  in  deeply  rooted  syphilis,  and  sometimes  in  that  which  is  not  yet 
rooted  ?  Why,  after  one  mercurial  course,  can  we  never  be  sure  that  a 
second  or  third  attack  will  not  appear,  and  infect  the  descendants?  And 
if  mercury  is  a  specific  in  the  scholastic  sense,  why  does  it  demand  the 
hygienic  and  therapeutic  conditions  which  all  diseases  and  treatments 
require  ?  Does  it  cicatrize  ?  Physiologically,  it  causes  ulceration.  When 
the  organism  is  unsound,  the  syphilitic  accidents  are  ill-defined,  depraved, 
lose  their  specific  distance,  as  Hunter  said;  in  a  word,  have  no  tendency 
to  spontaneous  cure.  Mercury  too  often  increases  this  unhealthy  dispo- 
sition. The  organism  must  be  modified  in  order  that  this  famous  spe- 
cific may  regain  its  power,  which  is  called  so  direct.  In  certain  very  ir- 
ritable persons,  opium  must  be  added  to  it,  or  it  will  not  act,  or  will  do 
harm  rather  than  good.  At  other  times  tonics  must  be  used  simultane- 
ously in  order  to  insure  success,  or,  it  will  cause  an  increase  in  the  vene- 
real symptoms,  unless  its  administration  is  preceded  by  venesection,  etc. 
It  is  exactly  as  in  the  case  of  remedies  which  are  not  in  the  least  specific. 
It  must  have  the  system  at  its  disposal,  just  as  if  it  were  a  common  rem- 
edy. Therefore,  it  does  not  act  alone;  it  does  not  neutralize  the  princi- 
ple of  the  disease  by  an  immediate  and  specific  action,  in  the  sense  of  the 
schools.     Nothing  is  more  conditional  than  its  effects. 

Syphilis  may  recover  spontaneously  at  a  certain  stage;  and  it  re- 
covers under  the  influence  of  mercury.  But  the  mediate  causes  or  con- 
ditions of  cure  may  be  very  various;  its  immediate  and  efficient  cause,  its 
principle,  if  we  choose,  cannot  differ  from  itself;  it  is  one  and  identical 
with  it.  Now,  syphilis  recovers  spontaneously,  or  rather,  the  organism 
cures  syphilis  by  its  own  power;  therefore,  it  cures  syphilis  when  mer- 
cury is  given.  We  also  conclude  that  it  is  impossible  that  this  should  be 
otherwise,  according  to  the  physiological  laws  which  we  have  stated,  and 
which  g-overn  all  treatment. 


ALTERATIVES.  221 

The  indication  for  alteratives  occurs  in  acute  and  chronic  disease, 

1.  In  acute  disease. — We  have  said  that  alteratives  are  in  place  at 
the  beginning  of  an  acute  disease,  when  it  is  necessary  to  modify  the 
crasis  of  the  blood  almost  instantly,  as  venesection  does  it.  There  are 
two  sorts  of  these  alteratives;  the  one  class  liquefy,  attenuate  the  blood 
directly  and  without  previous  excitement;  these  are  mercury  and  the  al- 
kalines;  the  others,  before  producing  their  effect,  cause  a  general  excite- 
ment, which  is  active  in  proportion  to  the  promptness  with  which  the  ef- 
fect is  sought;  these  are  arsenic,  iodine,  gold,  and  platinum.  The  latter 
should  never  be  used  in  acute  diseases. 

As  regards  mercury  and  the  alkalines,  with  which  we  might  class 
nitrate  of  potassium,  they  act  as  alteratives  without  intermediate  phe- 
nomena, almost  as  venesection  does.  For  example,  mercury  in  puerperal 
peritonitis,  synovial  rheumatism,  and  frank  acute  inflammation  of  the 
parenchyma  and  the  membranes;  and  the  alkaline  salts  of  sodium,  car- 
bonate of  potassium,  and  especially  nitrate  of  potassium  in  very  high 
doses,  in  the  same  circumstances. 

These  three  agents  must  not  be  used  indijfferently,  for  their  range  is 
far  from  being  the  same.  Mercury  alters  the  constitution  profoundly, 
sometimes  leaving  traces  which  last  for  months;  the  others  act  imme- 
diately with  almost  the  same  energy,  but  in  a  few  days  after  they  are 
given  the  system  forgets  them,  as  they  are  easily  assimilated  or  elimina- 
ted; nor  is  the  enfeeblement  they  produce  so  complete.  Hence,  the  two 
latter  are  to  be  preferred  when  it  is  to  be  feared  that  the  constitution 
may  give  way  as  soon  as  the  inflammation  has  gone;  the  former,  when 
the  patient  is  vigorous,  the  reaction  sustained,  or  the  disease  one  which 
may  be  expected  to  continue. 

In  typhoid  affections  (by  which  we  mean  not  only  dothinenteritis,  but 
all  disease  accompanied  by  typhoid  accidents)  we  are  especially  afraid  of 
remedies  whose  action  is  prolonged,  such  as  mercury,  and  for  a  very  sim- 
ple reason.  Bleeding  and  alterants  fulfil  well  the  indication  for  depres- 
sion in  cases  of  excessive  reaction  at  the  beginning  of  such  a  disease,  but 
bleeding  and  mercury  are  agents  whose  effects  are  protracted;  and  if 
the  period  of  stupor  and  debility  presently  comes  on,  we  shall  find  our- 
selves deprived  of  the  power  of  restoring  the  system  to  a  type  of  energy 
suitable  for  overcoming  the  malady.  We  cannot  then  restore  the  blood 
in  one  day,  nor  relieve  the  system  of  the  mercury,  with  which  its  tissues 
are  impregnated,  and  which  so  profoundly  debilitates  it.  In  this  case 
mercury  and  bleeding  should  be  continued  for  only  a  very  little  time ;  they 
should  be  stopped  as  soon  as  the  inflammatory  orgasm  begins  to  yield. 

2.  In  chronic  diseases. — When  a  disease  has  struck  deep  root,  when 
the  symptoms  increase  slowly  or  remain  stationary,  when  the  vital  organs 
are  involved,  or  a  local  affection  threatens  to  become  generalized,  it  is 
most  necessary  to  insist  on  remedies  to  relieve  the  cause  of  these  affec- 
tions, or  their  effects.  Sometimes  the  alterative  treatment  attacks  and 
neutralizes  the  cause,  and  the  lesions  produced  by  the  cause  are  after- 


222  THERAPEUTICS. 

wards  cured  by  nature's  efforts;  sometimes  the  cause  dies  out  for  some 
reason  which  we  may  not  recognize,  leaving  traces  of  its  action  which  are 
not  cured  spontaneously,  or  only  after  along  time,  and  an  alterative  relieves 
these  af  ter-eifects  without  generally  attacking  their  cause.  Thus,  mercury, 
gold,  and  iodine  seem  to  have  a  power  of  rendering  the  cause  of  syphilis 
harmless,  while  iodine  and  gold  seem  to  take  hold  only  of  the  consecutive 
symptoms.  In  more  exact  terms,  these  remedies  do  not  destroy  the  cause 
of  syphilis  when  it  is  evidently  present,  but  destroy  the  symptomatic  ac- 
companiments; whereas,  during  the  age  when  scrofula  is  making  progress 
and  consequently  is  a  real  existent  cause  in  the  system,  these  remedies 
seem  much  less  efficacious  than  at  the  period  Avhen  nothing  remains  to 
be  attacked  except  the  organic  changes  which  have  been  caused  by  suc- 
cessive attacks  of  the  scrofulous  distemper. 

There  is  something  quite  direct  in  the  action  of  alteratives  on  a  dys- 
crasia  or  a  virus;  there  is  nothing  visibly  interposed  between  the  cause 
and  the  effect.  The  behavior  of  the  remedy  to  the  system  in  health  gives 
no  indication  of  its  curative  power  in  syphilis  or  scrofula;  but  it  is  other- 
wise when  we  consider  them  independently  of  their  specific  mode  of 
action,  and  as  related  to  the  common  chronic  affections.  We  can  com- 
prehend, up  to  a  certain  point,  the  mechanism  of  the  Vichy  waters  in 
certain  engorgements  of  the  liver. 

In  certain  diseases  there  is  a  great  disturbance  in  the  chemical  consti- 
tution of  the  fluids  of  the  body.  Diabetes  mellitus  is  an  instance.  The 
blood,  in  this  affection,  is  a  little  less  alkaline  than  in  a  normal  state,  the 
salivary  fluid  becomes  acid,  and  by  virtue  of  the  tendency  of  the  system, 
starch  is  converted  into  glucose  on  entering  the  stomach,  more  quickly 
and  completely  than  is  natural;  and  the  absorbed  glucose,  circulating  in 
the  vessels  without  finding  sufficient  free  alkali  undecomposed,  passes  into 
the  urine  in  the  condition  of  grape  sugar,  having  first,  by  its  contact  with 
all  the  orga«s,  produced  severe  functional  disorders  and  a  cachexia  which 
at  last  betrays  itself  by  very  severe  organic  lesions. 

When  the  disease  is  not  very  far  advanced,  the  use  of  alkalines, 
especially  the  bicarbonate  of  sodium  and  magnesium,  is  almost  certain  to 
prevent  the  saccharine  transformation,  or  at  least  permits  the  sugar  to 
be  assimilated  and  decomposed  in  the  current  of  the  circulation  in  such  a 
way  as  not  to  be  passed  by  the  urine;  while  at  the  same  time  the  thirst 
diminishes,  the  perspiration  and  the  strength  reappear;  and  to-day, 
thanks  to  this  treatment,  there  are  a  considerable  number  of  cures,  more 
or  less  complete,  of  a  disease  formerly  thought  to  be  almost  beyond  the 
resources  of  art. 

Must  it  be  admitted  that  many  chronic  diseases,  and  even  some  acute 
ones,  may  be  considered  in  their  local  expression  as  the  result  of  an  acci- 
dental product  analogous  to  mould,  fungi,  or  lichens  ? 

It  certainly  cannot  be  denied  that  the  disease  in  general  causes  in  the 
system  certain  alterations  which  have  some  analogies  with  the  lower 
orders  of  the  animal,  and  even  of  the  vegetable  kingdom. 


ALTERATIVES.  223 

These  low  organisms  germinate  in  the  system  at  the  expense  of 
fluids  altered  by  disease;  they  develop  on  the  surface  or  in  the  sub- 
stance of  tissues,  and  form  local  lesions  which  cause  mechanical  im- 
pediments, and  become  foci  of  malignant  phlegmasije,  which  multiply 
themselves  indefinitely  as  by  a  sort  of  fermentation.  This  pathogeny 
is  easily  demonstrable  in  most  of  the  diseases  of  vegetables;  perhaps  it 
will  one  day  be  regarded  as  not  wholly  absurd  in  respect  to  men  and 
animals. 

This  idea  may  form  a  tolerable  basis  for  explaining  how  alteratives 
act  in  certain  chronic  diseases,  such  as  dartres,  cancers,  scrofula,  syphilis, 
the  causes  of  which  may  be  more  or  less  profoundly  modified  by  mercury, 
gold,  arsenic,  iodine,  etc.  Our  remedies  act  on  these  diatheses  as  upon 
the  diseased  surfaces  of  living  animals,  where  cryptogams  are  forming. — 
How,  then,  do  they  cure  these  last  degenerations  locally  ?  They  prob- 
ably do  it  by  impressing  upon  the  diseased  tissues  a  franker  and  more 
healthy  life,  and  thus  restoring  them  to  their  normal  nutrition  and 
secretions.  The  remarkable  point  in  these  remedies,  whether  general 
or  local,  is  that  each  diathesis  and  each  morbid  product  has  in  the  ma- 
teria medica  some  special  alterative,  which  may  be  called  specific,  if 
we  choose,  provided  that  we  do  not  seek,  in  the  occult  and  cabalistic 
action  which  this  expression  still  represents,  a  pretext  for  empiricism 
and  for  a  treatment  which  dispenses  with  the  need  of  being  a  phy- 
sician. 

Following  our  analogy,  we  see  that  each  species  of  cryptogamic  mor- 
bid product  in  animals  has  its  special  topical  remedy,  which  usually  suc- 
ceeds better  than  others. 

It  is  long  ago  that  our  master,  Bretonneau,  proved,  for  example,  that 
caustics  were  like  the  phlegrnasiae  in  possessing  specific  characters;  and 
that  the  burns  caused  by  each  could  be  distinguished  by  their  forms, 
course,  duration,  the  character  of  the  pain,  the  manner  of  cicatrization, 
etc. 

The  incontestable  truth  of  pathological  specificity  necessarily  implies 
that  of  therapeutical  specificity;  and  alterative  treatment  proves  this, 
both  by  the  agents  which  it  employs  and  by  the  diseases  to  which  they 
are  applied. 

In  conclusion,  we  would  offer  a  remark,  intended  to  meet  certain  well- 
founded  objections  to  the  classification  we  have  adopted. 

The  remedies  which  we  have  studied  in  this  chapter  are  not  exclusive- 
ly alteratives.  We  do  not  know  that  there  exists  in  medicine  a  remedy 
which  can  be  strictly  ranged  in  one  class.  Opium  has  with  justice  been 
placed  in  the  class  of  narcotics;  but,  on  the  other  hand,  opium  is  a  power- 
ful excitant  of  the  circulation,  a  sudorific,  aphrodisiac,  and  emmenagogue, 
as  gold  is  a  powerful  tonic  to  the  stomach.  Cod-liver  oil,  by  its  complex 
composition,  offers  as  much  difficulty  in  classification.  The  chemical 
principles  it  contains  (iodine,  bromine,  etc.)  give  it  a  place  with  these  al- 
teratives, while  its  most  marked  remedial  powers  would  seem  to  place  it 


224  THERAPEUTICS. 

with  analeptic  tonics.  We  would  indicate  two  things:  first,  the  difficulty, 
not  to  say  the  vanity,  of  classification;  and  further,  the  necessity  of  at- 
tending to  the  complex  qualities  of  drugs,  and  of  bearing  in  mind  that 
they  are  two-edged  weapons,  and  that  it  is  our  duty  to  be  able  upon  oc- 
casion to  use  one  of  the  qualities  and  neutralize  another  which  under 
given  circumstances  might  be  injurious. 


CHAPTER  lY. 

IRRITANTS . 

POTASSA. 

Caustic  potassa  is  usually  employed  to  open  issues.  Potassa  cum  calce 
is  preferable  to  pure  potassa,  because  it  spreads  less.  Of  late  years  the 
Vienna  caustic  has  been  preferred;  it  is  much  superior  to  potassa  with 
alcohol.  The  substance  is  applied  by  placing  on  the  skin  a  piece  of  dia- 
chylon plaster  with  a  hole  as  large  as  the  potassa.  The  latter  is  placed 
at  the  hole,  and  is  kept  there  by  another  bit  of  diachylon,  larger  than 
the  first,  and  compresses  and  bands  over  that. 

A  burning  sensation  is  felt  at  the  end  of  a  few  minvites,  and  then  an 
intense  burning  which  lasts  three  or  four  hours,  after  which  everything 
becomes  quiet.  On  raising  the  apparatus  at  this  time,  a  gray  spot  is 
seen,  a  little  soft  at  its  centre,  and  coriaceous  at  its  circumference.  This 
spot  usually  occupies  the  whole  thickness  of  the  derma,  and  is  four  or 
five  times  as  broad  as  the  diameter  of  the  piece  of  potassa.  This  cir- 
cumstance must  not  be  forgotten  in  selecting  the  potassa. 

The  eschar,  at  first  soft  and  moist,  soon  dries  and  takes  a  darker  tint. 
If  a  piece  of  diachylon,  or  any  other  substance  capable  of  retaining  moist- 
ure, is  constantly  applied  to  the  skin,  the  eschar  remains  soft  until  it 
falls. 

The  destroyed  portion  of  derma  falls  at  an  indeterminate  period;  if  it 
was  not  adherent  to  the  tissue  beneath,  it  usually  falls  in  from  six  to  ten 
days;  but  if  the  skin  is  thick,  it  may  not  be  detached  for  two  months. 
The  separation  from  the  quick  commences  at  the  circumference. 

The  size  of  the  eschar  and  the  slowness  of  the  separation  always  cause 
an  objection  to  the  use  of  caustic  potassa,  and,  in  general,  of  the  potential 
cauteries,  for  making  issues.  The  lancet  and  bistoury  are  certainly  pref- 
erable if  the  patients  are  not  timid. 

The  Vienna  powder  is  prepared  for  use  by  adding  alcohol  or  eau  de 
cologne,  and  making  a  firm  paste,  which  is  extremely  caustic,  and  has  the 
advantage  of  not  spreading.  M.  Hennau  [Revue  mecUcale,  1833,  t.  L,  p. 
212)  used  it  to  establish  issues.  He  required  from  six  to  ten  minutes  to 
form  the  eschar.  We  had  often  repeated  his  process  for  establishing  is- 
sues, when  it  occurred  to  us  to  employ  it  in  the  treatment  of  superficial 
cancerous  tumors,  especially  of  the  breast,  upon  which  subject  we  pub- 
lished a  paper  in  the  Journal  des  connaissauccs  medico-cJiirurgicales 
15 


226  THERAPEUTICS. 

(decembre,  3835).  A  caustic  paste  used  in  the  same  case,  composed  of 
lime,  potassa  and  opium,  lias  been  described  in  the  "  Pharmacopee  univer- 
selle"  of  Jourdan,  t.  II.,  p,  317. 

Since  the  publication  of  our  paper,  M.  Bonnet,  of  Lyons,  employed 
caustic  potassa  to  cauterize  the  skin  and  the  walls  of  veins  for  the  pur- 
joose  of  obliterating  the  chief  trunk  of  a  superficial  group  of  veins  on  the 
leg,  in  the  case  of  severe  varix  or  varicose  ulcer;  but  Aug.  Berard  justly 
prefers  the  Vienna  caustic  to  potassa  for  this  purpose.  He  has,  by  our 
advice,  attacked  nfevi  materni  with  the  same  caustic,  and  his  results  lead 
him  to  place  this  treatment  above  all  others,  at  least  in  most  cases. 

Several  surgeons  have  been  struck  with  the  bad  effect  of  the  too  fre- 
quent application  of  caustics  in  uterine  affections,  an  effect  which  led 
Amussat,  following  Dupuytren's  example,  to  use  caustic  potassa,  which 
is  powerful  enough  to  convert  all  the  altered  tissues  rapidly  into  an  eschar, 
so  that  only  a  few  applications  are  needed  in  order  to  give  a  complete 
cure.  But,  on  the  other  hand,  potassa  itself  has  inconveniences:  it  melts 
very  quickly,  and  may  flow  behind  the  speculum  down  the  posterior  sur- 
face of  the  vagina,  producing  eschars  which  in  some  cases  have  perforated 
the  recto-vaginal  septum.  Tliis  mishap  cannot  be  avoided  without  the 
most  minute  care.  The  following  preparation  has  been  made  by  M.  Fil- 
hos,  at  the  suggestion  of  Amussat: 

IJ, .   Potassa 300  grammes. 

Quicklime 100         *' 

These  are  put  into  a  large  iron  ladle  and  exposed  to  a  very  quick  fire. 
The  potassa  soon  melts,  and  the  lime  a  little  later.  When  l)oth  are  com- 
pletely liquefied  they  are  very  thoroughly  mingled  and  cast  in  cylinders, 
the  mould  having  first  been  warmed;«the  sticks  are  not  to  be  taken  out 
until  perfectly  cool.  The  melted  caustic  is  usually  poured  into  leaden 
tubes  with  thick  walls,  closed  at  the  ends,  and  kept  in  glass  tubes  con- 
taining quicklime  and  hermetically  stoppered.  The  cylinders  are  exces- 
sively hard.  They  quickly  absorb  the  moisture  of  the  air,  becoming  covered 
with  a  mixture  of  hydrate  of  lime  and  potassa.  To  preserve  them  for  an 
indefinite  time  they  may  be  covered  with  a  lamina  of  load,  or,  still  better, 
with  a  tJiin  layer  of  sealing-wax,  as  directed  by  M.  Dumeril  for  stick-nitrate 
of  silver;  they  are  afterwards  enclosed  in  glass  tubes,  which  are  carefully 
stoppered. 

This  caustic  adds  to  the  advantages  of  potassa,  that  of  not  melting 
so  quickly  when  used.  ]\I.  Fillios  directs  the  following  method  of  ap- 
plication. The  patient  is  placed  on  the  edge  of  a  high  bedstead,  her 
legs  supported  on  chairs,  and  her  back  so  high  that  the  vagina  takes  an 
oblique  position,  pointing  downwards  and  forwards,  so  that  the  liquids 
which  flow  from  the  cervix  uteri  may  pass  directly  into  the  speculum,  in- 
stead of  going  between  the  instrument  and  the  vaginal  canal.  The  full 
speculum  is  to  be  preferred.     It  is  to  be  oiled  and  introduced  carefully. 


IRRITANTS.  227 

and  the  cervix  well  exposed.  The  aii'ected  part  is  then  sponged  with  the 
greatest  care,  and  a  small  dossil  of  charpie  or  cotton  attached  to  a  long 
thread  is  introduced  in  front  of  the  anterior  extremity  of  the  lower  valve 
of  the  speculum,  immediately  below  the  neck  of  the  uterus;  this  is  to  pro- 
tect the  part  of  the  vagina  below  the  point  to  be  cauterized.  With  a  lit- 
tle practice  the  latter  operation  may  usually  be  dispensed  with;  it  prolongs 
the  operation  somewhat.  The  cylinder  is  next  applied,  held  in  a  porte- 
caustique  or  hxed  in  the  end  of  the  glass  tube  which  contains  it.  After 
the  cauterization  the  eschar  is  quickly  wiped  with  balls  of  charpie  grasped 
with  the  forceps,  which  is  placed  at  one  end  of  the  porte-caustique.  The 
dossil  of  charpie  is  then  promptly  removed  and  two  injections  of  cold 
water  are  made,  or  better,  of  water  slightly  acidulated  with  vinegar;  the 
injection  must  be  made  to  reach  the  neck  of  the  uterus.  The  acidulated 
water  neutralizes  the  small  amount  of  caustic  which  may  adhere  to  the 
eschar.  After  the  injection  a  small  piece  of  bandage  must  be  placed  in 
the  vagina,  with  the  lower  extremity  projecting  between  the  labia  ma- 
jora,  for  the  purpose  of  withdrawing  it.  The  patient  is  then  replaced  in 
her  bed. 

The  caustic  stick  must  be  exposed  only  at  one  end.  If  the  exposed 
end  is  covered  with  a  slight  crust  of  subcarbonate  of  lime  from  previous 
use,  it  must  be  rem6ved  with  a  tile.  The  action  may  be  made  more  vigor- 
ous by  dipping  the  caustic  lightly  in  alcohol,  brandy,  or  cologne  water. 
After  cauterizing,  the  cylinder  must  be  wiped  with  care  before  it  is  re- 
placed in  the  glass  tube. 

M.  Levrat-Perotton  has  recommended  caustic  potassa  for  ingrowing 
nail,  to  check  the  fungous  growth  ("Transact,  med.,"  t.  XL,  p.  41).  M. 
Solera  uses  it  as  a  cylinder,  covered  with  shellac  varnish,  in  treating 
lachrymal  fistula,  pterygium,  trichiasis,  unhealthy  ulcers,  ranula,  conti'ac- 
tions  of  the  rectum,  ulcerations  of  the  neck  of  the  womb;  and  to  perfo- 
rate the  membrana  tympani  {Bulletin  des  sciences  med.  de  Ferussac,  t.  XX., 
p.  336).  Without  sharing  M.  Solera's  exclusive  admiration  of  this  caus- 
tic, we  gladly  admit  that,  when  used  in  his  way  and  with  the  little  pre- 
cautions which  he  advises,  it  renders  very  great  service  in  surgery. 

Gimbernat  used  it  in  a  coUyrium,  in  the  dose  of  5  or  10  centigrammes 
to  30  grammes  of  distilled  water  (gr.  0*8 — 1"6  and  §  i.)  to  remove  macu- 
1;b  of  the  cornea.  Saviart  and  Cohen  dissolved  it  with  camphor  or  alco- 
hol in  water,  to  stimulate  indolent  ulcers. 

The  properties  of  subcarbonate  of  potassium  are  precisely  those  of 
potassa,  except  that  externally  it  can  only  be  used  locally  and  not  as  a 
caustic.  But,  in  all  cases  where  potassa  is  used  otherwise  than  as  a  scari- 
fier, it  is  much  better  to  use  the  subcarbonate.  Baths,  lotions,  vaginal 
injections,  and  pomades,  must  be  made  with  the  subcarbonate,  and  not 
with  pure  potassa.  These  local  applications  are  of  especial  use,  as  we 
have  said,  in  affections  accompanied  by  pruritus. 

The  specific  for  tinea,  of  the  brothers  Mahon,  is  only  a  mixture  of  alka- 
line substances  derived  from  the  ashes  of  srreen  wood. 


228  THERAPEUTICS. 

For  gouty  patients  with  very  marked  uric  diathesis,  Dr.  Galtier  Bois- 
siere prefers  the  alkalines  to  weak  organic  acids,  tartrates,  citrates,  malates 
of  potassium  especially,  and  also  of  sodium  and  magnesium,  to  all  other 
alkaline  carbonates,  and  even  to  the  alkaline  mineral  waters. 

He  uses  with  benefit  the  following  mixture,  usually  in  the  interval  of 
attacks,  but  also  at  the  beginning  or  end: 

Tartrate  of  postassium 50  grammes  (  3  xiiss.). 

"  "  sodium 30  "         (3  viiss.). 

"  "  magnesium 20  "         (3  v.). 

Mix,  pulverize,  and  divide  into  ten  papers,  each  containing  10  grammes 
(  3  iiss.). 

As  an  alkaline  drink,  take  daily  half  or  the  whole  of  a  paper  in  a 
large  cup  of  ptisan  of  inula,  orange,  or  ash. — As  a  purgative,  take  every 
week,  fortnight,  or  month,  three  or  four  papers  in  as  many  cups  of  the  same 
ptisan. 

For  external  use  in  gout,  M.  Galtier  Bossiere  much  prefers  potassa  to 
soda  and  the  other  alkalines.  In  gouty  affections  of  the  limbs,  when  there 
are  no  acute  pains  left,  he  has  often  used  general  or  local  baths,  in  which 
he  places  from  30  to  00  grammes  (say  3  i. — ii.)  of  caustic  potassa  for  a 
full  bath  of  300  litres  (quarts).  He  uses  a  solution  of  2  or  3  grammes 
(gr.  30 — 45)  to  a  quart  of  water  to  make  fomentations  in  tophus. 


Soda. 

This  substance  was  long  confounded  with  potassa;  and,  in  truth,  the 
chemical  and  physical  properties  of  the  two  are  almost  identical.  Its 
therapeutic  properties  are  almost  alike.  There  is,  however,  one  important 
distinction  to  make. 

In  external  use  there  is  little  difference;  whether  soda  be  used  with 
alcohol  or  lime  to  open  issues,  or  whether  subcarbonate  of  sodium  be 
used  in  solution  for  local  or  general  baths,  vaginal  injections  in  pruritus 
of  the  vulva,  etc. 

The  neutral  carbonate,  also  called  subcarbonate,  is  used  externally  as 
an  alkaline  and  irritant.  We  use  it  daily  in  soap.  This  is  a  substance 
of  remarkable  properties.  It  first  frees  the  skin  of  its  sebaceous  coat, 
and  softens,  the  superficial  layers  of  epidermis,  which  are  carried  away  by 
the  water,  and  thus  rids  the  skin  of  many  foreign  substances  which  are 
insoluble,  or  slightly  soluble  in  water.  The  epidermis,  scraped  off,  leaves 
the  skin  sensitive  to  the  action  of  the  alkaline,  and  an  increase  of  periph- 
eral circulation  follows,  with  a  certain  increase  in  the  heat  of  the  skin, 
which  often  lasts  several  hours  after  the  bath. 

The  bath  of  carbonate  of  sodium,  by  producing  this  peripheral  fluxion, 
has  a  valuable  derivative  action,  which  is  of  singular  use  in  aiding  the 
action  of  alkalines  taken  internallv.     This  effect  is  often  sufficient  to  ar- 


IRRITANTS.  229 

rest  certain  visceral  fluxions.  We  will  point  out  by  the  way  that  the  con- 
stipation of  young  children,  which  is  so  hard  to  treat  with  internal  reme- 
dies, yields  almost  immediately  to  the  alkaline  bath.  For  this  purpose 
we  do  not  dissolve  the  salt  in  the  bath,  but  soap  the  child's  body  all  over 
before  the  bath,  either  with  common  soap,  or  better,  with  black  soap, 
which  is  made  with  potassa. 


Silicate  of  Sodium. 

JBlennorrhagia. — M.  Gontier,  interne  of  M.  Marc  See,  at  the  Hopital 
du  Midi,  has  treated  seventeen  patients,  almost  all  in  the  acute  stage  of 
blennorrhagia,  and  the  majority  having  orchitis,  with  three  daily  injec- 
tions, containing  on  the  average  3  per  cent,  of  silicate  of  sodium.  All 
that  can  be  said  is  that  the  injection  was  usually  well  borne.  The  re- 
ports are  not  such  as  to  lead  to  a  substitution  of  this  for  ordinary  astrin- 
gent injections;  it  is  much  more  expensive,  and  perhaps  is  not  always  of 
uniform  composition.  The  same  may  be  said  of  the  treatment  of  non- 
infecting  chancres. 

■  Cystitis. — Dr.  Dubreuil,  surgeon  to  the  hospital  of  Lourcine,  has  em- 
ployed the  same  solution  in  cystitis  with  purulent  and  ammoniacal  urine, 
and  has  had  some  success  (Societe  de  chirurgie,  13  novembre,  1872). 
MM.  Gosselin,  Marc  See  and  Champouillon  have  obtained  analogous  re- 
sults; but  it  is  hard  to  say  how  much  is  due  to  silicate  of  sodium,  for  the 
washing  out  of  the  bladder,  and  the  care  taken  to  empty  it  completely, 
are  almost  sufficient  to  cure  the  disease  without  medicine. 

Others  have  sought  to  prove  that  there  is  a  category  of  mineral  waters 
which  owe  their  action  solely  to  the  amount  of  silicate  present.  Dr. 
Hugues,  physician  to  the  silicated  waters  at  Sail-les-Chateau-Morand 
(Loire),  who  had  proposed  this  theory,  claims  that  the  silicates  are  the 
only  active  principles  of  the  waters  of  Plombieres,  of  Evaux,  of  Arlanc 
and  Sail,  which  contain  from  0'13  to  0*25  grammes  per  litre  (quart).  This 
hypothesis  is  far  from  being  justified;  all  that  can  be  said  is  that  the  wa- 
ters of  Sail  accelerate  the  cure  of  ulcers,  whether  atonic,  varicose  or 
scrofulous.  The  attempt  to  make  these  waters  a  substitute  for  those  of 
Vichy  is  quite  unjustified. 

Lime. 

Lime  is  less  caustic  than  potassa  and  soda.  It  is  rarely  employed 
alone  as  a  caustic.  United  with  medical  soap  in  equal  proportions,  it 
was  formerly  used  to  destroy  warts  and  fungous  growths,  to  modify  the 
surface  of  certain  carcinomatous  sores,  and  to  destroy  some  superficial 
tumors  [Anclen  Journal  de  rnededne,  t.  LXXX.,  p.  309).  The  Vienna 
caustic  is  a  very  energetic  powder  composed  of  6  parts  of  quick-lime  and 
5  of  potassa;  and  the  pfite  d'Else,  composed  of  opium,  potassa  and  liine, 


230  THERAPEUTICS. 

may  also  be  of  much  use  in  surgery.     M.  Jobert  has  used  Vienna  caustic 
with  success  in  wens,  by  jiainting  it  on. 

An  Englisli  physician,  Dr.  Osborne,  has  proposed  in  the  Dublin 
Journal  a  new  method  of  cauterization,  to  take  the  place  of  the  ordinary 
moxa.  He  uses  for  this  purpose  quick-lime.  A  piece  about  12  milli- 
metres (0'4:7  inch)  thick,  as  fresh  as  possible  (this  condition  is  indispensa- 
ble to  success),  is  placed  in  a  porte-moxa,  or  on  a  card  pierced  at  its  cen- 
tre with  a  round  hole,  and  the  instrument  is  applied  to  the  skin  at  the 
point  to  be  burnt.  A  few  droj3S  of  water  are  then  let  fall  on  the  lime, 
which  immediately  swells  and  crumbles,  giving  rise  to  a  heat  of  about 
187'5°  centigrade  (369'5°  F.).  The  lime  must  be  withdrawn  before  all 
the  heat  of  which  it  is  capable  is  disengaged;  otherwise  the  derma  would 
doubtless  be  destroyed  in  its  whole  thickness.  It  is  of  course  easy  to  get 
an  eschar  more  or  less  deep,  according  to  the  length  of  time  the  lime  is 
left  in  contact  with  the  skin. 

Osborne  thinks  that  this  moxa  is  preferable  in  some  cases  to  all 
others.  It  gives  instantly  a  very  intense  heat,  with  the  advantage  of 
producing  an  action  at  once  rapid  and  deep,  without  terrifying  the  pa- 
tient with  the  sight  of  fire  and  the  sparks  which  burning  bodies  almost 
always  give  out. 

This  alkali  forms  the  basis  of  most  epilatory  pomades,  including  that 
used  by  the  brothers  Mahon  to  get  rid  of  the  hair  in  tinea,  which  is  at 
the  same  time  curative  of  the  disease;  also  of  the  epilatory  powders,  in 
combination  with  orpiment,  a  mixture  which  is  not  free  from  danger,  and 
may  even  cause  terrible  accidents  if  used  to  remove  hair  from  ulcerated 
surfaces. 

Tinea. — Bottger,  a  distinguished  chemist  of  Frankfort-on-the-Main,  was 
the  first  to  remark  the  very  energetic  depilatory  power  of  sulphohydrate 
of  sulphuret  of  calcium.  This  substance  is  obtained  by  causing  sulphu- 
retted hydrogen  gas  to  be  absorbed  to  saturation  by  a  pulp  composed  of 
two  parts  of  slaked  lime  or  dry  hydrate,  and  three  parts  of  water.  It 
forms  a  greenish-white  jelly. 

Tt  is  used  by  spreading  a  layer  of  about  two  millimetres  in  thickness 
(0-08  in.)  upon  the  part  from  which  the  hair  is  to  be  removed.  After  two 
or  three  minutes,  it  is  removed  with  an  ivory  knife  or  a  cloth,  and  the 
skin  is  found  entirely  freed  from  the  hairs,  without  any  excoriation  or 
injury  of  the  epidermis,  and  without  any  sensation  except  a  certain 
stinging. 

"While  recommending  the  trial  of  this  new  remedy,  we  must  warn  phy- 
sicians that  it  sometimes  attacks  the  skin  slightly,  and  often  produces 
redness  and  pain;  but  these  are  usually  too  slight  to  contraindicate  the 
remedy. 

Burns. — The  liniment  formed  of  a  soap  made  of  one,  two  or  three 
parts  of  lime-water  and  four  parts  of  oil  of  sweet  almonds,  is  especially 
recommended  by  Velpeau  in  the  treatment  of  burns;  it  has  been  of  real 
service  in   burns  of  the  three  first  degrees  ;   that  is,  up  to  the  degree  of 


IRRITANTS.  231 

severitj^  which   causes  the   mortification  of   the   skin    to  a  certain   depth, 
with  suppuration  and  a  cicatrix. 

When  there  is  simple  redness  or  blistering,  the  use  of  the  liniment 
often  causes  very  rapid  resolution. 

An  old  woman  received  a  burn  in  the  third  degree  upon  the  front  of 
the  chest.  The  suppuration  increased  her  debility  in  an  alarming  way, 
until  the  application  of  the  liniment  caused  desiccation,  and  the  strength 
was  restored  with  a  rapidity  which  was  unexpected  in  so  impoverished  a 
frame  {Bull,  de  the,'.,  t.  XIV,,  fevr.,  1838). 

Diseases  of  the  skin. — This  liniment  is  also  used  with  great  benefit  for 
the  cruel  itching  which  accompanies  some  dartrous  affections. 

Lime-water  is  used  externally  for  the  same  purposes  as  the  weak  solu- 
tions of  subcarbonates  of  sodium  and  potassium.  It  certainly  has  great 
power  to  heal  old  atonic  ulcers,  and  to  calm  itching  of  the  skin  and  of  the 
genitals;  as  a  gargle  it  is  useful  when  the  gums  are  soft  or  fungous,  and 
the  mucous  membrane  of  the  velum  and  the  tonsils  is  the  seat  of  old  and 
sluggish  inflammation. 

Diphtheria. — Numerous  experiments  show  that  lime-water  possesses 
a  power  of  dissolving  croupous  false  membranes,  which  is  superior  to  that 
of  the  solution  of  potassa  (one  of  the  best  solvents),  but  inferior  to  that 
of  lactic  acid. 

Vajjor-baths. — Caustic  lime  of  commerce  is  used  for  vapor-baths,  as 
follows:  a  piece  weighing  1  or  2  kilogrammes  (2 — 4  lbs.)  is  wrapped  in  a 
coarse  cloth  well  moistened,  and  placed  in  the  bed  of  the  patient,  the  cov- 
ei'ings  having  been  first  raised  and  supported  on  hoops.  When  the  water 
begins  to  be  absorbed  by  the  lime,  the  temperature  rises,  it  is  converted 
into  vapor,  and  if  fresh  water  be  added  from  time  to  time,  very  warm  and 
abundant  vapors  soon  arise,  forming  a  genuine  vapor-bath.  By  restrict- 
ing the  application  to  a  part,  a  local  vapor-bath  is  given. 

By  this  simple  and  inexpensive  method  we  have  dispelled  in  a  few 
days  various  rheumatic  pains,  especially  lumbago  and  sciatica,  which  had 
resisted  other  treatinent.  It  is,  however,  important  that  the  patient 
should  understand  the  action,  so  as  to  withdraw  the  lime  when  the  heat 
becomes  too  intense,  lest  he  be  burnt.  For  further  precaution,  the  lime 
should  be  wrapped  in  a  thick  cloth,  doubled  several  times,  and  not  too 
closely.  A  decoction  of  marshmallow  or  elder  may  be  substituted  for  the 
water,  if  desirable. 

Ammonia. 

Effects  of  External  Ajyplication. 

When  applied  to  the  skin,  concentrated  ammonia  rapidly  produces 
a  sensation  of  burning,  followed  by  redness,  vesication,  and  at  last  a  su- 
perficial eschar.  This  precious  property  has  been  of  great  use;  we  daily 
employ  it   in  preference  to  hot  water,  burning  alcohol,  and  other  means, 


232  THERAPEUTICS. 

the  action  of  which  ca!iiiot  be  so  readily  gauged.  The  same  substance 
is  also  used  in  cases  where  we  wish  to  produce  transient  redness  of  the 
skin.  For  the  latter  purpose  we  dip  a  piece  of  flannel  in  hartshorn 'and 
rub  the  skin  hard  with  it.  If  the  ammonia  is  from  18  to  23  degrees,  five 
minutes  are  sufficient  to  produce  the  desired  effect  upon  a  fine  and  vas- 
cular skin;  but  if  weak,  or  if  the  skin  be  thick  or  dirty,  a  much  longer 
time  is  needed.  The  erythema  thus  produced  rarely  lasts  beyond  two 
hours. 

For  producing  vesication,  various  methods  are  recommended.  The 
part  is  rubbed  with  flannel  or  a  piece  of  linen,  till  the  skin  is  raised. 
This  plan  succeeds  well,  but  is  excessively  painful  when  sensibility  is 
normal  and  the  derma  is  exposed  at  certain  points.  Some  persons  dip  a 
piece  of  blotting-paper  in  hartshorn,  but  without  result.  We  sometimes 
cut  a  compress  of  eight  or  ten  layers  of  the  desired  size  and  shape,  which 
we  soak  in  annnonia  of  at  least  12  degrees,  putting  on  fresh  as  fast  as  it 
evaporates,  so  as  to  keep  the  compress  saturated.  A  quarter  of  an  hour 
usually  suffices.  But  wc  often  have  to  wait  half  an  hour  or  an  hour,  no 
doubt  because  the  volatility  of  the  fluid  rapidly  deprives  it  of  its  effect. 
If  the  gas  is  retained  b}^  a  fatty  body  such  as  oil,  and  more  especially 
lard,  vesication  occurs  more  much  more  rapidly.  ])r.  Boniface  has  an  ex- 
cellent plan;  he  soaks  a  disk  of  agaric  with  ammonia  and  applies  it  by 
the  spongy  side;  the  impermeability  of  the  other  side  prevents  the  gas 
from  escaping,  so  that  vesication  occurs  almost  as  quickly  as  if  an  amino- 
niacal  liniment  or  ointment  were  used. 

M.  Bretonneau  has  long  used  a  thimble  or  a  small  tin  cup  filled  with 
carded  cotton  wet  with  ammonia.  This  device  increases  the  activity  of  am- 
moniacal  pomade,  and  we  advise  its  use.  It  becomes  of  great  importance 
when  the  exigency  demands  that  not  an  instant  of  time  be  lost. 

When  we  wish  to  use  the  ammoniacal  ointment,  we  model  with  the  spat- 
ula a  little  piece,  which  should  not  usualh^  exceed  the  diameter  of  a  franc 
piece.  At  the  moment  of  application  it  produces  a  transient  feeling 
of  cold,  to  which  a  sense  of  warmth  succeeds,  and,  after  a  few  minutes, 
that  of  burning.  This  is  by  no  means  so  painful  as  one  might  suppose, 
from  the  rapidity  of  the  vesication;  it  is  so  slight  that  a  real  pain  is  never 
complained  of.  The  epidermis  is  lifted  in  from  three  to  fifteen  minutes. 
The  seat  of  the  application  and  the  strength  of  the  pomade  make  a  great 
deal  of  difference.  We  do  not  lift  the  pomade  until  we  see  a  little  red 
areola,  which  is  a  certain  sign  that  the  blister  has  begun  to  form;  if  left 
on  longer,  the  pomade  might  produce  a  superficial  eschar. 

A\  hen  the  pomade  is  removed,  the  epidermis  is  sometimes  seen  form- 
ing a  single  bulla;  if  the  bulla  is  divided  into  several  cells,  it  is  well  to 
rub  the  epidermis  a  little  to  detach  it  more  completely;  the  folds  made 
by  rubbing  enable  one  to  seize  it  and  pull  it  off  more  easily.  The  exposod 
derma  is  pale  red;  if  bright  red  and  dotted  with  little  ecchymoses,  the 
ammonia  has  been  applied  too  long,  and  a  superficitil  eschar  is  the  result. 

Blisters  with  ammonia  are  usually  made  for  the  purpose  of  placing  on 


IRRITANTS.  233 

the  denuded  skin  medicinal  substances  which  are  to  be  absorbed.  After 
thus  applying  the  drug,  we  lay  a  small  piece  of  oil-silk  upon  it  directly, 
in  order  to  prevent  the  surface  from  drying  up;  it  is  aiterwards  covered 
with  a  piece  of  English  taffety,  which  extends  beyond  the  edges. 

At  the  second  dressing  the  surface  is  found  covered  with  a  yellowish- 
white  false  membrane,  which  sometimes  projects  above  the  level  of  the 
skin,  or  may  appear  sunken.  This  false  membrane  is  always  found  when 
the  dressing  is  applied  as  we  have  described  it,  varying  only  in  the  de- 
gree of  thickness,  which  is  always  proportionate  to  the  activity  of  the  po- 
made, the  duration  of  its  application,  and  the  time  elapsed  between  the 
first  and  second  dressing.  This  false  membrane  must  absolutely  be  re- 
moved, as  it  hinders  absorption. 

During  the  first  three  days  the  false  membrane  formed,  reproduced  at 
each  dressing,  is  easily  removed;  on  the  fourth  and  fifth,  it  is  closely  ad- 
herent to  the  derma,  and  has  a  sort  of  organization.  About  the  sixth  day 
nothing  is  seen  but  a  reddish  cicatrix,  which,  after  a  period  of  variable 
length,  disappears  entirely. 

If  the  pomade  is  applied  too  long,  a  superficial  eschar  is  produced  which 
is  hard  to  detach,  and  often  leaves  an  indelible  cicatrix.  When  we  desire 
the  caustic  effect,  we  leave  the  ammonia  in  contact  with  the  skin  for  half 
an  hour  or  longer;  but  the  result  is  much  less  rapid  and  certain  than  when 
potassa  and  lime  in  combination  are  employed. 

The  rubefacient  action  of  ammonia  is  employed  constantly  to  quicken 
sores  and  fistulas,  to  stimulate  the  skin  for  the  relief  of  chronic  engorge- 
ments, or  rheumatic  pains,  or  merely  to  provoke  a  derivative  fluxion. 

The  cauterant  effect  has  been  used  in  tic  douloureux  by  Herber,  of 
Nesti^sten,  following  the  example  of  Thilenius  ("  Biblioth.  med.,"  t. 
XLIII.,  p.  102),  and  in  toothache  caused  by  caries.  Gondret  ("  Consi- 
derations sur  I'usage  du  feu  et  sur  un  nouvel  epispastique,"  Paris,  1819) 
has  used  it,  and  with  success,  for  cauterizing  deeply  the  skin  of  the  scalp, 
for  the  cure  of  chronic  cerebral  affections,  incipient  cataract,  amaurosis, 
etc. 

A  little  ammonia  has  been  found  a  very  useful  ingredient  of  collyria 
for  a  large  number  of  acute  and  chronic  ophthalmias.  The  analogy  in- 
duced Pringle  to  order  it  in  gargles  for  angina,  in  the  jjroportion  of  15 — 
4C  grammes  to  500  (gr.  230 — 4G0  to  3  xvi.).  We  have  seen  tinea  treated 
by  Gondret  with  very  active  ammoniacal  lotions;  a  successful,  but  almost 
insupportably  painful  treatment.  Girard,  of  Lyons,  orders  it  diluted  with 
water  to  prevent  inflammation  in  burns;  MM.  Merat  and  de  Lens,  for  sim- 
ple fluor  aibus,  have  added  a  little  ammonia  to  the  injection.  Lavagiia, 
on  the  contrary,  produced  a  leucorrhoeal  flow  from  the  vulva  and  vagina, 
which  was  quickly  followed  by  the  menstrual  discharge.  This  was  his 
treatment  for  amenorrhoea,  and  Nisato  has  found  it  valuable.  The  injec- 
tion which  he  used  was  formulated  as  follows:  milk,  500  grammes  (1  pint) ; 
ammonia,  8 — 15  grammes  (  3  ii- — iv.). 

M.  Aran  has  often  repeated  the  ammoniacal  injections  recommended 


234  THERAPEUTICS. 

by  Lavagiia  and  Ashwell,  and  says  that  they  have  been  followed  by  very 
remarkable  results  in  the  case  of  young  virgins  in  whom  the  menses  ap- 
peared slowly.  He  puts  10  or  12  drops  in  30 — 45  grammes  (  3  i. — iss.)  of 
warm  milk,  and  increases  the  dose  by  5  drops  a  day  until  the  irritant  ef- 
fect is  hard  to  bear;  in  persons  who  are  not  irritable,  50  or  GO  drops  may 
be  used.  The  injection  is  taken  on  going  to  bed,  in  such  a  position  that 
the  liquid  is  retained  at  least  10  minutes;  they  are  repeated  several  davs 
in  succession,  and  sometimes  twice  a  day. 

But  though  ammonia,  used  topicalh',  has  restored  the  menstrual  flow. 
La  Pira  regards  it,  when  diluted  with  four  parts  of  water,  as  a  haemosta- 
tic; and  Girard,  of  Lyons,  prescribes  it  in  the  dose  of  4  grammes  (  3  i-)  to 
the  litre  of  water  (Oii.)  as  an  injection  in  ulcerated  cancer  of  the  cervix, 
to  destroy  the  odor,  relieve  the  pain,  and  lessen  the  h;vmorrhage. 

Ammonia  diluted  with  water  forms  a  viseful  application  in  gout.  M. 
Hutin,  physician  to  the  Hotel  des  Invalides,  used  to  have  applied,  to  feet 
affected  with  acute  articular  gout,  compresses  dipped  in  the  following 
solution: 

Aqua  aninionifo 4  grm.  (  3  i.). 

Water 150    "       (3  v.). 

This  is  very  soothing,  and  is  quite  in  general  use. 

Ammonia  forms  a  jjart  of  some  celebrated  cosmetics  for  stimulating 
the  growth  of  tlie  hair. 

Aqua  ammoniae o'54  gram.  [gr.  54'G], 

Essence  of  bitter  almonds .    o"54     "        [idem.] 

Spirit  of  rosemary 28"33     "        [gr.  430]. 

Essence  of  mace O'SS     "        [gr.  13]. 

Rose-water 75-00     "        [gr.  1,157]. 

Mix  first  the  essence  of  bitter  almonds  and  the  ammonia;  then,  after 
adding  the  essence  of  mace  and  rosemary,  stir  them  together;  add  last, 
by  degrees,  the  rose-water. 

The  external  use  of  ammonia  has  been  praised  by  some,  including  M. 
Ducros  of  Sixt,  who  place  a  brush  filled  with  liquid  ammonia  on  the  mu- 
cous membrane  of  the  pharynx  in  treating  nervous  asthma,  capillary 
catarrh,  whooping-cough  and  spasmodic  hiccup.  In  some  susceptible  ])a- 
tients,  the  immediate  inhalation  of  the  gas  which  occurs  at  the  instant 
of  application  causes  a  spasm  of  the  glottis,  so  that  respiration  may  be 
suspended  for  some  seconds,  and  life  seems  in  danger.  This  cauterization 
should  be  made  at  first  with  a  very  weak  solution,  and  afterwards  with 
concentrated  ammonia.  Some  obtain  the  same  results  by  cauterizing  the 
vault  of  the  palate. 

In  our  opinion,  the  latter  procedure  ought  to  be  generally  adopted, 
because  it  gives  exactly  the  same  result  without  the  same  dangers. 

In   performing  the  cauterization  we  use  a  brush,  which  is  first  wet 


IRRITANTS.  235 

with  concentrated  ammonia,  and  afterwards  dipped  lightly  in  water. 
Having  ascertained  by  smelling  that  the  vapor  is  not  in  excess,  it  is  car- 
ried to  the  velum  or  arch  of  the  palate,  on  which  it  is  very  rapidly  painted. 
Three  or  four  seconds  suffice. 

After  a  moment  of  anxiety  and  a  fit  of  coughing  followed  by  the  ex- 
pectoration of  mucus  streaked  with  blood,  the  patient  recovers,  and  usu- 
ally says  that  he  is  considerably  better;  the  dyspnoea  has  disappeared, 
or,  if  there  were  any,  the  attacks  of  suffocation.  In  most  cases,  no  douVjt, 
the  remission  is  only  temporary,  but  it  is  nevertheless  true  that  in  some 
cases  the  attack  of  asthma  is  cut  short;  and  some  physicians  claim  to 
have  obtained  complete  cures. 

The  simplest  plan,  and  the  one  which  we  use  most  commonly,  con- 
sists in  keeping  in  the  room  a  vessel  of  w'ater  containing  some  ammonia; 
this  seems  to  be  often  of  service  in  nervous  asthma. 

Synco2)e. — Ammonia,  or  rather  its  vapor,  is  used  daily  in  cases  of  syn- 
cope, or  when,  after  any  cerebral  trouble,  the  consciousness  is  long  in  re- 
turning. We  need  not  speak  of  the  great  objections  to  the  long  continued 
inhalation  of  ammonia.  It  is  proper  to  stimulate  the  mucous  membrane 
of  the  nose  and  larynx  by  this  remedy,  but  the  observations  of  Majault 
("  Reflexions  sur  quelques  preparations  chimiques,"  etc. ;  Paris,  1779), 
those  of  Fourcroy  ("  Encycl.  meth."),  and  of  Percy  {Bull,  dela  Faculte  de 
Paris,  1815,  p.  517),  prove  that  so  energetic  and  dangerous  a  remedy 
should  not  be  entrusted  to  unskilled  or  careless  hands,  as  is  constantly 
done. 

Sage,  an  observer  worthy  of  some  confidence,  has  quickly  restored  ani- 
mals to  life  after  asphyxia  by  carbonic  acid,  by  making  ammoniacal  vapor 
penetrate  the  bronchi  and  nasal  fossae.  Was  recovery  due  to  the  fact 
that  the  nerves  were  simply  stimulated,  or  that  the  carbonic  acid  contained 
in  the  air-passages  was  neutralized  ? 

To  obtain  a  less  rude  effect,  the  English  have  bottles  containing 
muriate  of  ammonium  and  carbonate  of  potassium.  The  mutual  action 
of  these  two  salts  is  slow  and  disengages  a  small  quantity  of  ammonia- 
gas. 

Venomous  poisons. — The  popularity  of  ammonia  for  the  treatment  of 
the  bites  of  venomous  animals  is  founded  on  the  celebrated  case  of  Ber- 
nard de  Jussieu,  wdiich  has  been  so  ill  observed  and  interpreted.  Fonta- 
na,  the  most  logical  of  toxicologists,  and  the  most  ingenious  and  skilful 
of  experimenters,  has  in  vain  proved  the  puerility  of  Jussieu's  observa- 
tion ("Exp.  sur  le  venin  de  la  vipere");  in  vain  has  he  proved  a  thou- 
sand times  that  the  bite  of  the  viper  and  the  stings  of  most  poisonous  in- 
sects rarely  cause  death;  it  is  still  believed  that  eau  de  luce  and  ammo- 
nia prevent  the  death  of  the  few  persons  who  take  them.  We  have  never 
seen  the  symptoms  of  poisoning  by  the  bite  of  venomous  brutes  in  any 
I'espect  modified  by  the  outward  or  inward  use  of  hartshorn:  and,  far 
from  sharing  the  opinion  of  Manglini  ("  Sul  veneno  della  vipera,"  1809), 
of  Sonnini  {Journal  de  Physique,  1776,  t.  YIII.,  p.  474),  and  of  Sage, 


236  THERAPEUTICS. 

we  adhere  to  that  of  Fontana  and  Gaspard  [Jburn.  de  phys.  de  Magen- 
die,  t.  I,,  p.  248),  namely:  that  ammonia  and  its  combinations,  such  as 
eau  de  luce,  are  at  least  useless,  and  even  harmful  when  they  give  a  false 
security  and  prevent  the  use  of  more  efficient  means. 


Compounds  of  Ammonia. 

The  principal  compounds  used  in  medicine  are  the  carbonate,  the  ace- 
tate and  the  muriate  of  ammonium. 


Carbonate  of  Ammonium. 

This  salt,  a  strong-  alkali,  owes  its  therapeutic  virtues  to  ammonia 
only.     The  dose  is  twice  as  large. 

In  England,  this  salt  is  used  in  cases  of  syncope  and  epilepsy,  the  pa- 
tient being  made  to  inhale  it,  with  precautions;  it  is  kept  in  a  wide- 
mouthed  bottle  with  ground  stopper,  and  the  salt  is  flavored  with  various 
aromatics. 

Applied  externally,  carbonate  of  ammonium,  like  ammonia,  may  pro- 
duce rapidly  all  degrees  of  irritation,  from  rubef action  to  cauterization. 
Chaussier  preferred  it  to  Gondret's  pomade,  which  loses  its  virtues  in  a 
few  days  (Merat  and  De  Lens:   "Diet,  de  mat.  med,,"  t.  I.,  p.  245). 

Carbonate  of  ammonium  is  an  ingredient  in  an  American  hair-wash: 

Tincture  of  the  leaves  of  myrcia  acris.  .  140  grammes  (2100  gr.). 

Essence  of  laurel ' 1.77"          (27.2  gr.). 

Bicarb,  ammonium 28.00  "          (432  gr.). 

Borax 28.00  " 

Rose  water 1.13  litres  (quarts). 

Mix  and  filter. 

Acetate  of  Arnm.onium. 

What  we  have  said  of  the  carbonate  may  be  said  of  the  acetate.  We 
ought,  however,  to  mention  what  Boerhaave,  Cullen,  Selle  and  many 
others  have  said  of  the  spirit  of  Mindererus;  all  of  whom,  and  our  own 
contemporaries  also,  ascribe  to  the  acetate  a  power  of  rendering  the  cir- 
culation, tlie  secretions,  etc.,  more  active — a  power  which  it  shares  with 
the  volatile  alkali  (Cullen:  "Mat.  med.,"  t.  II.,  p.  3G6;  Selle:  "Obs.  de 
med.,"  p.  70).  As  to  its  effect  in  intoxication  (Mazuyer:  Gazette  de 
sante,  nov.,  1826),  upon  migraine  {Ibid.),  and  on  the  uterine  pains  which 
accompany  the  monthly  flow,  it  seems  entirely  like  that  which  we  have 
alread}'  ascribed  to  ammonia.  But  the  acetate  has  lately  been  used  in  quite 
a  special  way  as  a  sedative  of  the  uterine  action.  M.  Patin  has  reported 
several  observations  showing  that  if  given  in  cases  of  excessive  or  too  fre- 
quent menstruation,  or  even  in  cases  of  haemorrhage  from  uterine  cancer, 


IKPwITANTS.  237 

it  lessens  the  amount  or  the  frequency  of  the  flow.  In  this  case  we  give 
15  grammes  in  the  24  hours,  in  four  doses.  The  same  authority  has 
often  found  acetate  of  ammonia  useful  in  cases  of  difficult  and  painful 
menstruation,  causing  the  pain  to  cease  and  thus  assisting  the  flow. 
E'rom  50  to  72  drops  may  be  given,  divided  into  two  doses  and  mixed 
with  a  o-lass  of  sweetened  water.  The  first  dose  is  to  be  taken  as  soon  as 
the  pains  and  malaises  of  the  monthly  period  are  felt;  the  second,  if  nec- 
essary, is  taken  half  an  hour  later,  and  may  be  increased  according  to  the 
severity  of  the  symptoms. 

He  reports  a  case  of  nymphomania  treated  with  great  success  by  this 
remedy.  Then  he  draAvs  certain  analogical  inductions,  to  wit:  that  ace- 
tate of  ammonia  might  be  of  much  use  to  women  who  are  inclined  to  abor- 
tion by  the  flow  of  blood  towards  the  uterus  which  occurs  in  inflamma- 
tions of  the  womb  and  the  ovaries,  and  in  organic  lesions  of  those  parts 
{Arch.  gen.  de  nied.,  t.  XVIIL,  p.  217). 


Muriate  of  Ammonium. 

In  the  chapter  on  alteratives  we  mentioned  the  internal  administra- 
tion of  this  salt  for  the  relief  of  catarrhal  affections.  We  now  study  it 
from  a  very  different  point  of  view.  In  1837,  Fuchs  of  Gottingen  at- 
tempted to  apply  it  directly  to  the  mucous  surfaces.  In  1838  and  '30,  he 
published  an  account  of  his  success  in  treating  chronic  bronchitis  by  the 
inspiration  of  the  vapor  of  muriate  of  ammonium,  produced  by  throw- 
ing the  salt  upon  heated  plates.  The  treatment  was  introduced  in  France 
by  Professor  Lasegue,  and  then  abandoned.  Lowin  of  Berlin,  thinking 
that  this  abandonment  was  due  to  a  rude  method,  devised  an  apparatus 
for  disengaging  the  substance  in  a  nascent  condition;  the  patient  in- 
spires at  will,  and  in  amounts  which  can  be  regulated,  and  is  not  suffoca- 
ted by  the  vapor,  as  in  Fuchs'  procedure. 

Luwin's  inhaler  is  composed  of  three  bottles  of  unequal  size,  the  larg- 
est holding  120  grammes  of  distilled  water,  while  the  two  smaller,  con- 
taining each  60  grammes,  are  filled  with  muriatic  acid  and  caustic  am- 
monia respectively. 

Libermann,  physician  to  the  military  hospital  of  Gros-Caillou,  brought 
this  apparatus  to  our  notice,  and  has  used  it  since  18G8.  His  conclusions 
are  as  follows: 

The  patient  who  uses  the  apparatus  must  begin  by  breathing  moder- 
ately. He  feels  the  vapor  traversing  his  larynx,  and  giving  rise  to  a 
sharp  prickling.  The  first  effect  is  a  lively  irritation  of  the  mucous  mem- 
brane, which  increases  the  catarrhal  secretions,  but  easily  subsides  by 
degrees.  A  part  of  the  salt  is  absorbed  and  passes  off  by  the  urine. 
The  circulation  is  accelerated;  there  is  a  feeling  of  heat,  and  even  a  little 
sweating  and  diuresis.  The  cough  and  the  hypera?sthesia  of  the  respi- 
ratory mucous  membrane  are  quieted. 


238  THERAPEUTICS. 

As  a  result  of  the  treatment,  the  chronic  granular  angina  which  suc- 
ceeds the  inflammatory  affection  usually  disappears  quite  soon.  In  her- 
petic angina,  the  inhalation  gives  a  little  relief,  but  does  not  cure.  In 
chronic  bronchitis  it  lessens  the  amount  of  the  secretion  and  quickly  dries 
it,  but  the  stimulant  nature  of  its  first  effects  prohibit  its  use  in  acute 
tuberculous  bronchitis.  It  has  some  efficacy  in  convulsive  coughs  and 
the  various  forms  of  idiopathic  asthma  {Bulletin  de  thenqjeutique,  30 
octobre,  1873). 

Ruete  of  Guttingen  considers  sal  ammoniac  a  powerful  preventive  of 
suppression  of  the  perspiration  of  the  feet,  saying  that  in  his  experience 
it  has  proved  infallible.  In  cases  of  suppression,  particularly  in  gouty  or 
rheumatic  patients,  who  do  not  usuall}^  bear  foot-baths  well,  and  yet  need 
to  have  perspiration  re-established,  he  has  always  obtained  the  best  results 
within  a  few  days.  He  powders  a  stocking  with  a  small  spoonful  of  sal 
ammoniac  and  twice  as  much  quick-lime;  the  patient  puts  on  this  stocking 
before  going  to  bed,  and  wears  it  all  night.  In  the  lightest  cases  it  suf- 
fices to  repeat  the  procedure  a  few  times;  in  obstinate  cases  the  stocking 
must  be  freshly  charged  in  the  morning,  to  be  worn  all  day. 

In  this  mixture  the  acid  of  the  salt  combines  witii  the  lime,  and  the 
liberated  ammonia  must  be  considered  the  most  active  principle.  An 
agreeable  warmth  is  felt  in  the  feet;  a  slight  prickling,  itching,  and  in  a 
short  time  an  abundant  sweat  ("Encycl.  des  sc.  medic:  extrait  des  jour- 
naux  allemands,"  3e  cahier,  juillet,  1839). 


Chlorine. 

Infectious  diseases. — The  power  which  chlorine  has  of  decomposing 
almost  all  organic  products,  and  depriving  them  of  smell,  has  led  some 
ph3-sicians  to  think  that  it  would  neutralize  morbific  miasms  and  check 
epidemics.  Tliere  is  no  kind  of  absurd  falsehood  and  apocryphal  or  ill- 
observed  fact  that  has  noi  been  published  upon  this  subject;  but  we  have 
very  recent  and  sad  experience  of  the  uselessness  of  the  remedy.  At  the 
beginning  of  the  yellow  fever  which  devastated  Gibraltar  in  1828, 
chloride  of  lime  was  thrown  into  all  the  sewers  of  the  town  and  into  the 
gutters,  was  placed  in  all  the  barracks,  and  given  away  to  all  the  inhabi- 
tants. Terror  made  ever^"^  one  observe  this  regulation  faithfully;  and 
yet,  three  months  later,  there  were  scarcely  oOO  inhabitants  that  had  not 
]iaid  tribute  to  the  epidemic.  When  the  cholera  invaded  Paris  and 
France,  we  know  what  vainly  prodigal  use  was  made  of  the  disinfectant 
chlorides.  As  regards  epidemics,  chlorine  and  the  chlorides  are  })robably 
useless.  We  cannot  deny  their  disinfecting  power;  but  there  are  many 
persons  to  whom  their  odor  is  less  tolerable  than  that  of  the  smell  they  re- 
place. 

If  chlorine  and  the  chlorides  used  as  disinfectants  are  useless  in  pre- 
venting epidemics,  may  they  not  have  more  valuable  pi'operties  when  ap- 


IRRITANTS.  239 

plied  topically,  and  when  chlorine  is  brought  directly  in  contact  with 
organic  matter  charged  with  the  virus  ?  Experience  alone  could  prove 
this,  and  facts  nuist  have  great  value. 

It  is  said  by  most  faithful  observers  that  the  plague  is  transmitted  by 
the  garments  of  those  who  have  had  the  disease.  Experiments  made  by 
the  medical  commission  sent  to  Egypt  in  1829  showed  that  such  clothes, 
washed  in  water,  macerated  in  a  weak  solution  of  chlorinated  soda,  and 
dried  in  the  sun,  may  be  worn  next  the  skin  with  impunity.  A  little  re- 
flection will  show  how  inconclusive  such  experiments  are,  and  how  ill- 
founded  the  conclusions  which  are  claimed;  for  it  is  certain  that  a  good 
washing  in  simple  water  renders  the  garments  of  plague-patients  harmless. 

Hydrophobia. — Chlorine  and  the  chlorides  are  said  to  be  capable  of 
destroying  the  poison  of  rabies.  Brugnatelli,  in  1810,  was  the  first  to  cele- 
brate these  properties  with  enthusiasm.  He  washed  the  fresh  wounds 
with  liquid  chlorine,  and  gave  it  internally,  in  the  dose  of  1^  grammes 
for  children  (gr.  19)  and  8  grammes  for  adults  (  3  ii.),  four  or  five  times  a 
day  during  several  weeks  [Journ.  gen.  de  rned.,  t.  LIX.,  p.  303).  Other 
Italian  physicians  subsequently  confirmed  these  statements  (Arragoni: 
Bidl.  de  la  soc.  med.  d^emuL,  fevr.,  1823,  p.  127).  In  France,  M.  Cheval- 
lier  used  it  successfully  for  a  student  in  pharmacy  who  had  been  bitten 
by  a  mad  dog.  Schonberg  and  Semmola  {Bulhitm  des  sciences  raedl- 
cales  de  Ferussac,  mai,  1828)  testify  to  the  same.  Semmola  claims  to 
have  cured  nineteen  persons  who  were  bitten  by  dogs  that  were  certainly 
hydrophobic.  He  washed  the  bites  with  chlorine  diluted  with  water, 
and  dressed  them  twice  a  day  with  a  pledget  of  chai'pie  soaked  in  the 
same.  At  the  same  time  he  gave  chlorine  for  forty  or  fifty  days,  from  8 
to  30  grammes  (  3  ii — viii.)  three  times  a  day,  diluted  with  a  proper 
amount  of  sweetened  water.  He  gives  a  story  which  he  thinks  demon- 
strative. Three  persons  had  been  bitten;  two  underwent  the  treatment 
and  had  no  symptoms,  but  the  third  refused,  and  died  with  hydrophobia 
twenty-three  days  after  the  bite.  There  is  one  grave  objection  to  Schon- 
berg's  and  Semmola's  statements:  "•'  Are  you  sure,"  we  might  ask  them, 
"•  that  your  careful  cleansing  of  the  bites  was  not  a  chief  cause  of  the 
favorable  result — and  would  not  washing  with  pure  water  have  had  the 
same  effect '?  " 

In  response  to  such  objections  M.  Costa  took  a  dog  which  presented 
all  the  symptoms  of  confirmed  hydrophobia,  and  inoculated  two  well 
dogs  with  the  saliva  in  five  or  six  places,  besides  causing  the  other  to  bite 
them  in  several  spots.  Six  hours  later,  the  wounds  of  one  dog  were  care- 
fully washed  in  a  solution  of  chloride  of  sodium  in  one-half  its  bulk  of 
water,  which  was  also  injected  to  the  bottom  of  the  wounds.  The  other 
dog  was  washed  with  equal  care,  but  in  pure  water.  The  results  in  the 
two  cases  were  very  different.  The  dog  which  had  been  treated  with 
chlorine  presented  no  sign  of  the  disease,  but  the  other  died  in  thirty- 
seven  days  with  all  the  symptoms  of  rabies  {Journal  des  2^}'0(/7'cs,  t.  XITL, 
p.  233). 


240  THERAPEUTICS. 

The  fact  reported,  conclusive  as  it  seems,  proves  nothing,  except  that 
lotions  and  injections  made  with  an  irritant  substance  such  as  solution  of 
chlorine  and  the  alkaline  chlorides,  may  modify  the  virus  in  the  wound 
and  prevent  hydrophobia. 

Such  a  conclusion  would  not  seem  justified  if  it  were  not  for  large 
numbers  of  facts,  which  have  been  collected  by  Trolliet  "  Recherches  sur 
la  rage,"  and  Stanislas  Gilibert  ("  Compte  rendu  de  la  societe  de  medecine 
de  Lyon  depuis  1812  "),  and  which  unhappily  disprove  the  great  proin- 
ises  of  Brugnatelli  and  those  who  held  his  views.  It  would  certainly  be 
culpable  to  neglect  certain  and  heroic  means  in  favor  of  a  treatment 
which  may  have  been  successful,  but  which  is  so  much  in  dispute. 

J^arioke. — With  more  reason  and  success,  Gubian  of  Lyons  washes 
the  surface  of  the  body  in  confluent  variolae  with  chlorinated  water,  at  the 
period  when  the  pus  begins  to  be  fetid  {Journal  de  chimie  nied.,  t.  VL, 
p.  316);  Boyer  of  Marseilles  injects  it  into  the  cavities  of  large  absces- 
ses which  keep  up  a  resorptive  fever  {Gaz.  med.,  1834,  p.  196);  that  Re- 
camier  ("  Le9ons  orales  declinique");  Deslandes  ("Nouv.  biblioth  med.," 
t.  VIIL,  p.  151)  pass  chlorinated  injections  into  the  uterus  when  the  pla- 
centa or  any  mass  is  putrefying  in  the  cavity  of  the  organ.  For  the  same 
purpose,  Reid  of  Dublin  gives  injections  and  washes  of  chlorinated  lime 
or  soda  to  change  the  odor  of  the  dysenteric  stools  and  lessen  the  inflam- 
matory irritation  of  the  mucous  membrane  of  the  large  intestine.  Cotte- 
reau  and  Chevallier  also  recommend,  in  order  to  destroy  the  smell  of  pus 
in  oza?na,  and  to  cleanse  ulcers  of  the  pituitary  membrane,  the  inha- 
lation of  chlorinated  powders  or  liquids. 


Hydrochloric  Acid. 

Ulcers. — Liquid  hydrochloric  acid,  the  only  form  which  is  now  used 
in  m'edicine,  is  one  of  the  most  common  caustics;  the  eschar  which  it 
causes  is  superficial,  and  the  sore  which  follows  the  fall  of  the  eschar 
cleans  rapidly.     Internally  it  is  an  irritant  and  powerful  poison. 

This  acid  was  lauded  by  Boerhaave,  Van  Swieten,  Marteau,  Granvil- 
liers,  but  was  hardly  used  in  our  time  until  Bretonneau  of  Tours  called 
attention  anew  to  its  useful  properties,  employing  it  in  pseudo-membran- 
ous diseases  of  the  mucous  membranes  to  produce  superficial  cauteriza- 
tion (see  "  Traite  de  la  diphterite  ").  He  directs  that  the  acid  shall  be 
fuming.  He  observes  that  this  acid,  like  most  mineral  acids,  coagulates 
the  albumin  which  enters  into  the  secreted  mucus,  and  which  also  pro- 
duces a  pellicular  inflammation  which  must  by  no  means  be  confounded 
with  that  of  which  we  desire  to  prevent  the  formation,  the  reproduction, 
or  the  extension.  An  error  of  this  sort  led  M.  Baup  to  say  that  hydro- 
chloric acid  propagates  diphtheritic  inflammation.  The  same  acid  is  used 
topically  by  the  illustrious  practitioner  of  Tours  to  combat  certain  chronic 
scalv  diseases  of  the  skin. 


IRRITANTS.  241 

Some  years  ago  Ricord  made  at  the  Hopital  des  Veneriens  a  success- 
ful application  of  concentrated  muriatic  acid  to  the  treatment  of  mercu- 
rial ptyalism.  He  had  remarked,  as  many  others  had  done,  that  the  sali- 
vation did  not  depend,  as  was  said,  upon  a  direct  irritation  of  the  sali- 
vary glands  by  mercury,  but  upon  the  inflammation  of  the  gums,  which, 
whether  mercurial  or  not,  always  gave  rise  to  salivation.  He  considered 
that  the  treatment  ought  to  be  directed  entirely  towards  the  f)reventing  the 
mercurial  inflanmiation  of  the  gums.  As  soon  as  he  sees  the  gums  of  the 
lower  incisors  begin  to  swell,  he  cauterizes  them  straightway  with  fum- 
ing muriatic  acid,  and  repeats  the  operation  once  every  day  until  the  in- 
flammation is  dissipated.  He  performs  the  operation  with  a  little  brush, 
wliich  he  passes  lightly  over  the  gums,  taking  care  to  avoid  the  teeth. 

In  sanious  ulcers  of  the  tonsils,  the  gums,  the  cheeks,  in  aphthae,  or 
muguet,  muriatic  acid,  pure  or  mixed  with  half  its  weight  of  honey  of 
roses,  rapidly  cleanses  the  mucous  membrane.  It  has  been  used  with 
equal  success  in  hospital  gangrene,  a  disease  accompanied  by  diphtheritic 
and  pultaceous  exudations  quite  analogous  to  those  which  are  developed 
on  the  mouth  and  tonsils  (see  for  quotations,  Gmelin:  "  Apparatus  med.," 
pars  II.,  vol.  i.,  p.  53). 

Some  physicians  have  recommended  for  chilblains  lotions  made  with  a 
mixture  of  muriatic  acid  and  water  (Linne,  quoted  by  Gmelin,  loco 
supra  dicto;  Journ.  de  Vcmclermonde,  t.  VII.,  p.  154).  This  means  has 
seemed  to  us  quite  efficacious  in  general.  Rowley  reported  the  cure  of 
erratic  gout  by  placing  the  feet  in  a  bath  acidulated  with  hydrochloric 
acid  ("  Treatise  of  the  regular,  etc.,  gout,"  London,  1793).  Plueck  profes- 
ses to  have  cured  an  obstinate  tinea  with  a  pomade  composed  of  one  part 
of  muriatic  acid,  one  of  ointment  of  althea,  and  four  of  juniper  ointment 
(Vide  Gmelin,  p.  55,  1.  c.) 

Internally,  muriatic  acid  has  been  recommended  as  an  antiseptic, 
under  the  same  circumstances  as  chlorine;  or  as  a  temperant,  under  the 
same  conditions  as  other  acids  (see  t.  II.,  "  Medicaments  sedatifs  "). 

The  acid  was  used  as  a  disinfectant  long  before  chlorine;  Guyton,  of 
]Morveau,  in  1773  first  used  it  by  fumigation  to  disinfect  the  tombs  of  Di- 
jon and  the  dungeons  of  the  city  prison,  where  the  mortality  was  great. 

Mode  of  administration  and  doses. — The  acid  may  be  used  concen- 
trated; it  is  commonly  mixed  with  honey  or  water,  in  proportions  so  va- 
riable tliat  it  is  impossible  to  indicate  them  here.  For  foot-baths,  from 
125  to  250  grammes  (  §  iv. — viii.)  are  usually  put  into  6  or  8  quarts  of  hot 
water. 

At.kaline    Chloridks. 

Javelle's  water  has  long  been  used  in  the  arts  for  bleaching;  it  was 
generally  known  in  1789.     Percy  is  said  {Hevue  w.edicale,  1826),  but  on 
very  questionable  authority,  to  have  used  it  in  the  army  of  the  Rhine,  in 
1793,  for  hospital  gangrene. 
16 


242  THEEAPEUTICS. 

Chloride  of  lime  was  named  by  Guyton  de  Morveau,  in  18U1,  as  a  dis- 
infectant (1.  c),  and  in  1803  by  Alyon  {Annal.  de  chimle,  t.  LIII.),  as  a 
preventive  of  contagion. 

But  the  first  authenticated  use  of  chlorides  plainly  belongs  to  Masuyer, 
of  Strasburg.  In  his  "  (3bservations  sur  la  maladie  dite  fievre  des  hopi- 
taux,"  published  in  1811,  he  describes  the  property  possessed  by  chloride 
of  lime,  of  slowly  disengaging  chlorine;  by  means  of  which  he  disinfected 
the  air  of  hospital  wards.  The  writings  of  Gimbernat,  Bories,  and  Patis- 
sier  followed;  and  Labarraque  subsequently  described  most  distinctly  the 
disinfecting  powers  of  the  various  alkaline  chlorides. 

Labarraque  did  not  actually  demonstrate  the  disinfecting  powers  of 
the  chlorides,  but  by  his  enthusiasm  (perhaps  exaggerated)  he  compelled 
physicians  to  use  them  in  all  kinds  of  internal  and  external  diseases.  In 
the  years  1825,  '26  and  '27,  they  threatened  to  carry  by  storm  the  whole 
of  surgical  therapeutics,  whose  walls  had  been  breached  by  the  school  of 
the  Val-de-Grace;  but  by  degrees  the  fashion  passed  by,  and  the  chlorides 
fell  into  their  jjroper  place. 

We  have  no  more  to  say  of  the  chlorides  as  disinfectants,  but  will 
confine  ourselves  to  properties  which  are  not  solely  due  to  chlorine. 

The  chlorides,  in  virtue  of  their  great  alkalinity,  have  been  used  ex- 
ternally, and  have  properties  like  those  of  solutions  of  carbonate  of  sodi- 
um and  potassium,  and  lime-water.  This  is  probably  the  explanation  of 
their  numerous  applications  in  surgery. 

In  urethral  blennorrhagia,  and  more  especially  in  that  of  the  vagina; 
and  in  leucorrhoea  caused  by  inflammation  of  the  neck  of  the  uterus  or  a 
chronic  inflannnation  of  the  vaginal  mucous  membrane,  injections  of 
chloride  of  lime,  sodium  or  potassium  are  useful  for  the  same  reason  as 
alkaline  solutions  (Daumas:  "Theses  de  la  Faculte  de  Paris,"  1825,  No. 
120;  Blache  et  Jolly:  "Diet,  de  mcd.,"  2e  6d.,  t.  VII.,  p.  431). 

In  pruritus  of  the  vulva  (Darling:  Med.  Jiepositori/,  Feb.,  182G),  in 
superficial  herpetic  affections  (Alibert:  "Nouv.  elem.  de  ther,,"  t.  II.,  p. 
453), in  itch  (Derheims,  Fontanetti:  "Hospital  Transact.  Med.,"  t.  X.,  p. 
385;  Jouni.  des  con)i.  jned.,  t.  I.,  p.  233),  in  some  diseases  of  the  scalp 
(Chevalier:  "  Art  de  preparer  les  chlorures  ;  "  Roche,  Cottereau:  Ibid.);  the 
alkaline  chlorides  possess  neither  moreaiorless  virtue  than  the  solutions  of 
lime,  potassa,  or  soda,  which  are  generally  successful  in  such  circumstances. 

It  is  probably  due  to  the  same  property  and  mode  of  action  tliat  the 
chlorides  act  favorably,  not  only  on  blennorrhagic  opththalmia  and  ure- 
thral blennorrhagia,  but  also  on  scrofulous,  and  even  epidemic,  ophthal- 
mia (Varlez:  "  Diet,  de  Merat  et  de  Lens,"  t.  IL,  p.  359;  Guthrie:  Lon- 
don Med.  and  Phys.  Journal,  Nov.,  1827;  Hesberg:  Gaz.  med.  de  Paris, 
1831,  p.  183). 

In  the  above  affections,  the  chlorides  probably  owe  their  value  to  their 
alkalinity.  Whether  this  is  true  also  in  the  diseases  we  are  now  about  to 
mention,  is  a  matter  for  observation  to  decide. 

Lisfranc,  one  of  the  strongest  partisans  of  the  chlorides,  who  has  used 


IRRITANTS.  243 

them  with  great  benefit  for  chronic  ulcers,  attributed  to  them  a  special 
efficacy  in  the  case  of  burns;  saying,  with  Dupuytren,  that  no  treatment 
was  more  effective  in  burns  of  the  second  or  third  degree;  but  the  experi- 
ence of  others  by  no  means  confirmed  their  statement,  and  the  two  claim- 
ants for  the  honor  of  the  discovery  have  themselves  given  it  up. 

In  the  treatment  of  hospital  gangrene,  and  diphtheritic  and  pultaceous 
inflammation  of  the  mouth,  which  so  often  causes  fatal  gangrene  of  the 
cheeks  in  children,  the  treatment  by  chlorides  has  proved  very  successful, 
according  to  Percy  (Merat  et  de  Lens),  Darling  (1.  c),  and  Roche  (see 
Chevalier)  and  Bonneau,  physician  to  the  Children's  Hospital  at  Paris, 
(Blache:  "Diet,  de  med.,"  2e  edit.,  t.  VIII.,  p.  434).  The  latter  uses  exclu- 
sively the  dry  chloride  of  lime.  He  commonly  takes  a  piece  of  paper, 
rolled  up,  wets  the  surface  by  dipping  it  in  water,  then  dips  it  into  a 
bottle  of  the  chloride,  and  passes  it,  covered  with  powdered  chloride,  over 
the  affected  parts.  After  a  minute  or  two  he  causes  the  patient  to  gar- 
gle in  order  to  get  rid  of  the  chlorine,  which  might  irritate  the  neighbor- 
ing parts. 

Dr.  Hervieux  has  very  recently  proved  the  very  remarkable  efficacy  of 
a  dressing  of  chloride  of  soda,  diluted  with  three,  four  or  more  parts  of 
water,  according  to  the  irritability  of  the  part,  and  applied  on  pieces  of 
sponge  to  ulcers  of  bad  character, 

M.  Simeon  proposes  chlorine  in  poisoning  by  hydrocyanic  acid,  the 
clilorine  combining  with  the  hydrogen  and  setting-  free  cyanogen.  Orfila 
finds  the  antidote  very  effective;  he  uses  a  mixture  of  four  parts  of  water 
and  one  of  solution  of  chlorine.  Mialhe  prefers  to  pass  under  the  patient's 
nose  a  compress  wetted  with  vinegar-water  into  which  chloride  of  lime 
has  been  put. 

SiLVKR, 

Solutions  of  nitrate  of  silver  have  been  used  locally  and  with  success 
in  inflammation  of  all  the  mucous  membranes — as  the  conjunctiva,  the 
nasal  fossa^,  the  pharynx,  the  mouth,  the  vagina,  cervix  uteri,  ui-ethral 
canal,  and  bladder.  Chronic  inflammations  within  the  cavity  of* the  neck  of 
the  womb  or  on  its  surface  are  particularly  benefited  by  nitrate  of  silver, 
solid  or  in  solution ;  especially  in  cases  of  erosion,  granulation  or  ulcer- 
ation, accompanied  by  an  abundant  muco-purulent  discharge,  or  loss  of 
blood,  which  often  fatigues  or  exhausts  the  patient. 

Many  acute  inflammations  are  similarly  relieved,  as  diphtheritic  angina, 
croup,  catarrhal  angina,  oedematous  angina,  acute  blennorrhagia,  the  most 
intense  blennorrhagic  ophthalmia,  purulent  ophthalmia  and  dysentery. 

A  somewhat  severe  attack  of  quinsy  may  very  often  be  aborted  by 
cauterization  with  the  crayon  or  the  concentrated  solution,  provided  the 
application  be  made  at  the  beginning.  At  a  later  period  the  same  appli- 
cation may  shorten  the  duration  of  the  disease.  The  relief  is  almost  im- 
mediate; the   pain  and  difficulty  in  swallowing  subside  almost  instantly. 


244  THEEAPEUTICS. 

In  order  to  make  the  cure  complete,  it  is  sometimes  necessary  to  repeat 
the  cauterization  once  or  twice,  at  the  interval  of  twelve  or  twenty-four 
hours.  The  same  treatment  is  used  successfuU}''  in  scarlatinous  angina  of 
the  tonsils,  with  the  effect  of  cutting  it  short  or  at  least  diminishing  con- 
siderably the  symptoms,  when  they  threaten  to  become  unusually  grave, 
owing  either  to  excess  of  inflammation  or  to  a  complication  with  diph- 
theria. 

At  the  beginning  of  a  cold,  Tessier,  of  Lyons,  uses  with  success  a  weak 
solution  of  nitrate  of  silver  as  an  abortive;  it  is  spread  repeatedly  over 
the  nasal  cavities. 

For  the  skin,  when  in  consequence  of  inflammation  it  is  converted  in- 
to a  highly  vascular  membrane  (as  the  surface  of  ulcers);  in  fistulous  pas- 
sages; in  the  various  chronic  cutaneous  affections,  the  topical  applications 
of  nitrate  of  silver  are  very  often  successful;  and  in  a  great  many  cases 
of  skin  diseases  it  was  Alibert's  principal  remedy. 

It  appears,  therefore,  that  nitrate  of  silver  has  been  used  with  benefit 
in  the  majority  of  inflammations  of  the  skin  or  the  mucous  membranes. 
Yet  we  may  say  that  it  is  best  indicated,  and  shows  its  curative  powers  in 
the  highest  degree,  in  specific  inflammation  and  ill-conditioned  sores,  or 
generally  in  diseases  which  do  not  proceed  frankly  to  resolution.  It  is  in 
general  use  for  venereal  inflammations.  Acute  vaginitis  is  now  attacked 
vigorously  with  the  crayon,  or  preferably  with  more  or  less  concentrated 
solutions,  which  are  painted  over  the  whole  surface  of  the  vulvo-uterine 
canal.  In  certain  forms  of  blennorrhagia  in  men,  quite  strong  injections 
are  in  very  frequent  use;  but  if  the  disease  is  limited  at  first  to  the  fossa 
navicularis,  cauterization  with  the  cra3'on  often  causes  it  to  abort,  accord- 
ing to  Cahen. 

Nitrate  of  silver  incorporated  with  lard  was  long  ago  used  in  certain 
ophthalmias  of  the  lids.  Jobert  (de  Lamballe)  used  it  locall}'  in  the  er}'- 
sipelas  and  the  inflammation  of  the  lymphatics  and  veins  which  follow 
wounds  and  surgical  operations.  He  believes  that  surgical  erysipelas 
does  not  differ  from  that  due  to  internal  causes,  both  being  dependent  on 
a  special  condition  of  the  system.  He  further  thinks  that  the  local  mani- 
festation of  the  general  condition  deserves  the  most  serious  consideration, 
and  that,  while  seeking  to  reclaim  the  general  condition,  we  must  at  any 
cost  extinguish  the  ervsipelatous  region,  which,  after  great  operations  oj- 
wounds,  is  suflJicient  to  cause  death.  He  has  a  pomade  containing  one  or 
two  parts  of  nitrate  of  silver  to  four  of  lard,  which  he  spreads  twice  a 
day  over  all  parts  of  the  skin  that  are  attacked  or  threatened  with  in- 
flammation. This  ointment  blackens  the  parts,  and  causes  a  strong  sen- 
sation of  burning,  with  a  very  acute  vesicular  inflammation;  but  the  ery- 
sipelas usually  disappears,  and  is  fixed  in  the  region  where  the  inflamma- 
tion caused  by  the  ointment  exists.  The  nitrate  of  silver  ointment  is 
now  preferred  by  some  to  croton  oil  for  producing  local  inflammations; 
but  it  gives  a  very  disagreeable  color  to  the  skin,  and  an  indelible  stain 
to  the  clothing. 


IRRITANTS.  245 

In  pruritus  of  the  vulva,  that  so  troublesome  and  so  obstinate  disease, 
almost  always  due  to  a  herpetic  irritation  of  the  skin  which  spreads  to 
the  mucous  membrane  of  the  labia  and  vagina,  washes,  cauterizations  or 
injections  with  a  solution  of  nitrate  of  silver  render  more  marked  service 
than  calomel  and  sublimate. 

In  eruptive  diseases,  including  small-pox,  impetigo  and  zona,  several 
practitioners  have  followed" the  advice  of  Bretonneau  of  Tours,  and  di- 
rected a  light  cauterization  of  the  derma  on  which  the  pustule  or  bulla  is 
situated  with  nitrate  of  silver,  in  order  to  produce  abortion  of  the  local 
inflammation. 

A  superficial  application  of  nitrate  of  silver  causes  large  granulations 
upon  the  surface  of  ulcers  to  disappear  very  rapidly.  Ducamp  applied 
the  analogy  to  the  treatment  of  engorgements  of  the  mucous  membrane 
of  the  urethral  canal;  and  the  value  of  this  remedy  is  now  well  known. 
We  have  used  the  same  treatment  to  produce  resolution  of  chronic  en- 
gorgement of  the  tonsils;  and  have  thus  often  cured  an  affection  for 
which  the  only  resource  used  to  be  extirpation. 

Contractions  of  the  nasal  duct,  the  internal  and  external  auditory 
meatus,  the  nasal  fossa?,  and  even  the  lower  part  of  the  rectum,  have  been 
cured  by  this  treatment,  which  must  be  governed  by  the  condition  of  the 
parts,  the  severity  and  duration  of  the  disease. 

We  might  speak  of  the  value  of  local  applications  of  nitrate  in 
superficial  ulcerations  of  the  cornea,  the  buccal  mucous  membrane,  the 
glans,  prepuce,  etc.  It  would  be  impossible  to  quote  the  multitude  of 
cases  in  which  it  has  been  used;  there  is  no  agent  in  medicine  that  is 
more  frequently  used.  But  we  may  sum  up  by  saying,  that  it  is  of  very 
special  service  in  a  great  many  acute  or  chronic  inflammations  of  the  skin 
and  mucous  membranes;  its  efiicacy  in  these  eases  is  so  well  established 
that  it  deserves  the  name  of  the  antiphlogistic  caustic. 


Subcutaneous  Ixjectioxs  of  Nitrate  of  Silver. 

Until  very  lately,  the  use  of  irritants  as  revulsives  has  been  confined  to 
the  coverings  of  the  body — the  skin,  mucous  membranes,  membranes  of 
the  bladder,  etc.  A  distinguished  physician  of  Rheims,  M.  Luton,  has  in- 
troduced these  agents  into  the  subcutaneous  cellular  tissue,  and  even  the 
parenchyma  of  the  viscera.  He  gives  to  this  method  the  name  of  paren- 
chymatous substitution  (Acad,  des  Sciences,  38  septembre,  1863).  He 
has  employed  many  irritant  substances — solution  of  chloride  of  sodium, 
alcohol,  tincture  of  cantharides,  of  iodine,  etc. — but  he  prefers  to  all  these 
the  solution  of  nitrate  of  silver,  one  part  to  five  or  ten.  When  first  in- 
jected, it  causes  a  severe  pain,  which  grows  less  during  the  day,  so  that 
the  patient  can  almost  always  sleep  on  the  following  night.  The  pain  is 
usually  less  on  the  next  day,  but  soon  reappears;  and  a  boil  is  formed 
which  almost  always  has  to  be  opened  from  the  eighth  to  the  tenth  day. 


246  THERAPEUTICS. 

The  discharge  is  at  first  a  sanious,  blackish,  thin  pus,  containing  rags  of 
mortified  cellular  tissue;  it  afterwards  improves  and  the  abscess  heals. 
When  only  a  few  drops  are  injected,  a  regular  furuncle  is  developed. 

This  method,  then,  gives  pain  for  ten  days.  But  if  we  consider  that 
most  of  the  affections  for  which  it  is  used  threaten  to  last  a  long  time, 
or  had  produced  atrophy  of  the  limb  (as  sciatica),  we  shall  not  find  the 
price  too  high  to  pay.  For  neuralgias  of  the  face  and  trunk  the  case  is 
not  quite  the  same,  and  there  are  few  who  would  care  to  risk  a  phlegmon 
of  the  face. 

Thiersch,  pursuing  his  method  of  injecting  modifying  substances  into 
tumors,  employed  for  cancers  a  solution  containing  2  parts  of  nitrate  of 
silver  to  1,000  of  water:  and  then,  to  prevent  the  diffusion  of  the  caustic 
(though  probably  there  is  no  need  to  fear  it),  he  used  a  second  injection 
of  chloride  of  sodium  containing  1  part  in  1,000  of  water.  The  silver  in- 
jection amounted  to  30  or  40  grammes  (  3  viii. — x.)  of  fluid;  that  of  com- 
mon salt,  to  15  or  20  (  3  iv. — v.).  His  intention  was  to  impregnate  the 
elements  of  the  neoplasm  and  produce  atrophj'.  He  pierced  the  tumor 
in  all  directions,  to  reach  as  much  tissue  as  possible.  This  painful  oper- 
ation required  the  employment  of  ana?sthesia  by  chloroform.  It  gave 
small  results,  and  Thiersch  afterwards  proposed  to  make  the  injection  by 
the  arteries  (  Wiener-  Wochenschrtft,  June  2G,  1867). 

The  indications  and  rules  for  the  use  of  nitrate  of  silver  are  given  in 
the  chapter  on  irritants. 

SuLPHUBic  Acid. 

Sciatica. — The  treatment  of  sciatica  bj-  sulphuric  acid  originated  with 
Legroux  of  the  Hotel-Dieu  {Bulletin  de  therapeutique,  septembre  et 
octobre,  1852).  It  has  replaced  with  advantage  the  cauterization  \i\ 
hot  iron,  the  accompaniments  of  which  are  always  terrifying.  His  ex- 
ample has  been  followed  by  some  others,  among  whom  may  be  named 
Loiseau  of  Paris,  H.  Gintrac  of  Bordeaux,  Dubourg  of  Marmande,  and 
we  have  often  used  it  ourselves.  The  method  usually  causes  the  succes- 
sive disappearance  of  all  the  painful  points,  and  in  a  short  time  the 
majority  of  the  patients  are  cured,  and  the  rest  markedly  improved. 
This  result  is  the  more  valuable,  as  sciatica  is  notoriously  the  most  obsti- 
nate of  all  neuralgias. 

Legroux's  method,  which  we  also  follow,  is  thus  described. 

One  or  two  tablespoonfuls  of  commercial  sulphuric  acid  are  put  into 
a  plate;  a  piece  of  cotton  wadding  is  dipped  into  it,  and  the  painful  por- 
tion of  the  sciatic  nerve  is  stroked  with  the  cotton  from  above  downwards. 
This  leaves  a  stripe  about  3  centimetres  broad  (1^  inches),  and  of  a  length 
proportioned  to  the  number  of  painful  spots.  If  the  whole  length  of  the 
nerve  is  abnormally  sensitive,  we  do  not  cauterize  all  at  once  the  whole 
length,  but  only  one-third  or  one-half  of  the  most  painful  part,  to  avoid 
too  extensive  a  burn.     We  also  avoid  covering  the  bony  prominences,  in 


IRRITANTS.  247 

order  to  leave  the  patient  free  points  for  his  body  to  lie  upon.  If  suppu- 
ration ensues,  we  find  it  well  to  dress  with  an  astringent  solution,  usually 
of  tannin,  which  coagulates  the  gelatine  produced  by  the  cauterization. 

Sebaceous  ^<<///ors.— Specialists  have  long  competed  with  surgeons  by 
the  announcement  that  they  cure  tumors  with  caustics  instead  of  the 
knife.  If  the  word  "tumors,"  which  is  far  too  general  and  pretentious, 
be  replaced  by  "  sebaceous  tumors,"  it  will  give  the  truth.  The  things 
which  are  removed  by  acid  caustics  are  wens  and  lipomata. 

When  we  can  see  over  a  lipoma  the  point  formed  by  the  closed  orifice 
of  the  follicle,  the  destruction  of  a  small  portion  of  skin  at  that  point  will 
suffice  for  the  removal  of  the  cystic  pouch;  but  when,  as  is  most  common, 
the  point  is  not  visible,  the  whole  or  a  great  part  of  the  skin  over  the 
tumor  is  destroyed.  As  the  cyst  has  hardly  any  attachment  except  that 
to  the  skin,  from  which  it  receives  its  vessels,  it  shrinks  after  the  oper- 
ation, and  is  cast  off  with  the  eschar.  There  is  sometnnes  a  difficulty. 
The  hairy  scalp  is  one  of  the  favorite  seats  of  the  disease;  when  the 
tumor  occupies  that  situation,  it  may  become  adherent  to  the  pericranium, 
and  remains  so  when  the  eschar  is  detached.  This  complication  may  be 
foreseen,  for  it  is  easy  to  learn  beforehand  whether  or  no  the  tumor  is 
fixed  by  its  lower  surface;  and  there  will  be  no  serious  obstacle  if  the  ad- 
hesions are  slight,  as  they  may  be  destroyed  with  the  scissors  without 
much  risk. 

Dr.  Chairou,  physician  to  the  convalescent  hospital  of  Le  Vcsinet,  pre- 
fers as  an  acid  caustic  the  "  pate  safranee-sulfurique"of  Velpeau,  which  lie 
uses  for  extracting  sebaceous  tumors  as  M.  Gillet  of  Grandmont  uses 
chromic  acid.  His  results  were  communicated  to  the  Societe  de  Chirur- 
gie  (November  10,  1869),  and  reproduced  in  M.  Neyreneuf's  thesis.  He 
has  extracted  o3  sebaceous  cysts  from  11  persons.  The  eschar  generally 
fell  from  the  10th  to  the  35tli  day;  the  sore  was  dressed  with  a  simple 
piece  of  dry  charpie,  and  healed  in  a  few  days. 


Zinc. 

We  shall  speak  hereafter  of  oxide  of  zinc,  which  we  have  classed  with 
antispasmodics  in  accordance  with  the  custom  of  most  of  our  predeces- 
sors, though  we,  for  want  of  conclusive,  experience,  are  not  able  to  affirm 
positively  that  such  are  its  powers. 

We  shall  review  briefly  first  the  soluble  preparations,  the  chloride, 
sulphate,  and  acetate  of  zinc,  and  afterwards  the  insoluble  preparations, 
the  oxide  and  carbonate. 

Chloride  of  zinc  is  used  internally  as  an  antispasmodic;  it  is  danger- 
ous, and  less  useful  than  the  other  preparations  of  zinc.  We  shall  give 
our  chief  attention  to  its  external  use.  It  is  caustic,  but  in  a  less  degree 
than  those  which  we  shall  mention.  When  applied  pure  and  in  powder 
to  the  epidermis,  it  inflames  it,  and  in  six  or  seven  hours  causes  a  grayish 


248  THERAPEUTICS. 

eschar,  which  is  detached  a  little  more  quickly  than  those  produced  by 
caustic  alkalies.  This  caustic  property  has  been  utilized  by  some  modern 
physicians.  Hanke  of  Breslaii  used  it  to  destroy  n;«vi  materni,  fungus 
hasmatodes,  malignant  pustules,  and  syphilitic  ulcers  of  carcinomatous 
appearance  [Hulletm  des  sciences  med.  de  Ferussac,  t.  X.,  p.  74;  Journ. 
de pharmacie,  t.  XVI.,  p.  549).  More  recently  M.  Canquoin,  who  pre- 
tended to  possess  a  secret  remedy  for  cancel",  was  obliged  to  publish  it 
after  it  had  ceased  to  be  a  secret;  but  from  that  time,  the  famous  remed}- 
worked  no  more  miracles,  and  was  forgotten  as  soon  as  known.  His  caustic 
paste  has  little  effect  upon  skin  covered  with  epidermis,  which  must  be 
first  stripped  off  by  the  aid  of  ammoniacal  ointment;  the  paste  is  then 
applied  for  one  or  two  da^^s  according  to  the  depth  to  which  it  is  desired 
to  cauterize  the  tumor.  This  method  is  very  slow,  and  is  so  horriblv 
painful  that  the  most  courageous  often  refuse  to  have  it  repeated. 

We  cannot  here  discuss  the  comparative  advantages  of  the  caustic 
method  of  treating  tumors  as  compared  with  that  by  the  knife.  We  Avill 
only  name  the  writings  of  Estor  ("  De  la  methode  cauterisante,"  in  Jour- 
nal de  la  societe  de  medecine  jiratlque,  1840) ;  of  Girouard  ("  Etude  pour  le 
chlorure  de  zinc,"  Revue  niedico-chlrnr(/.,  1844) ;  of  MM.  Salmon  and  Mau- 
noury  (  Gaz.  medlcale,  1859);  and  the  "Theses of  the  Facultc  de  medecine 
of  Paris,"  sustained  by  MM.  E.  Bonnet  (1843),  Hardy  (1853),  Vieillard 
(185G),  Fontagneres  (18G9),  Simbal  (1874),  and  Philippeaux's  "Treatise 
on  Cauterizd,tion." 

We  shall  restrict  ourselves  to  a  mention  of  tlie  procedures  whicli  have 
been  retained  by  surgeons. 

Fistulas  of  various  kinds  are  dailj-  treated  at  the  Val-de-Grace  by  M. 
Gaujot,  with  arrows  of  chloride  of  zinc,  as  recommended  by  MM.  Salmon 
and  Maunoury. 

Maisonneuve  does  not  destroy  the  tumor  from  without  inward,  but 
forms  a  sort  of  trench  between  the  affected  and  the  healthy  portions  In- 
pushing  in  fragments  of  chloride  of  zinc  paste,  cut  into  "  arrows,"  or  tri- 
angular pieces,  each  measuring  a  centimetre  or  a  centimetre  and  a  half  at 
the  base,  and  10  to  15  centimetres  (4  to  G  inches)  in  length.  As  this 
substance  has  little  action  on  the  skin,  a  puncture  is  first  made,  which  is 
pushed  as  deep  as  the  limits  of  the  lesion,  if  possible.  The  blade  of  the 
bistoury  is  then  withdrawn,  and  in  its  place  is  inserted  an  arrow,  which  is 
broken  off  at  the  level  of  the  skin.  The  arrows  are  thus  placed  like  the 
spokes  of  a  wheel  or  the  slats  of  a  Venetian  blind,  with  intervals  of  only 
2  centimetres  (0*8  in.),  which  is  sufficient  to  enable  the  adjoining  arrows 
to  destroy  the  tissues  between  them. 

In  two  or  three  hours  the  action  of  the  caustic  is  marked  by  a  little 
grayish  line  surrounding  the  base  of  the  arrow.  In  six  hours  this  space 
has  a  breadth  of  about  2  millimetres  (O'OS  in.);  and,  in  36  hours,  of  one 
centimetre  (0*4  in.).  During  this  time  the  arrow  softens,  but  does  not 
become  fluid.  When  well  formed,  the  escliar  is  surrounded  by  a  line  of 
demarcation  which  increases  by  degrees,  but  never  exceeds  1^  or  2  centi- 


IRRITANTS.  249 

metres  (0"G — 0*8  in.).  Elimination  begins  at  the  fiftli  day;  and,  if  the 
arrows  have  been  well  placed,  so  as  to  form  a  complete  trench,  the  tumor 
falls  on  the  eleventh  day. 

It  is  remarkable  that  the  chloride  of  zinc  prevents  the  tumor  from 
putrefying-,  but  embalms  it,  as  it  were.  The  sore  left  by  the  fallen  eschar 
is  red,  covered  with  granulations,  and  quickly  heals  if  it  rests  on  a  com- 
pletely healthy  tissue. 

Professor  Richet  (Gaz.  des  hop.,  juillet,  1869)  has  proposed  to  treat 
sebaceous  cysts  by  injecting  into  their  interior  a  very  small  quantity  of  a 
solution  of  chloride  of  zinc  by  a  subcutaneous  syringe.  On  the  third  day 
the  hole  made  by  the  needle  becomes  more  distinct;  it  is  marked  by  a 
small  crust,  which  increases  by  degrees;  from  the  eighth  to  the  twelfth 
day  it  is  large  enough  to  enable  us  to  enucleate  the  tumor  by  simple  pres- 
sure. 

Nitrate  of  zinc,  XnO,  N05,  3H0. — This  salt  has  lately  been  proposed 
as  a  substitute  for  the  chloride  by  M.  Latour,  chief  apothecary  at  the 
military  hospital  of  Lyons.  It  is  obtained  by  the  reaction,  in  the  warm, 
of  nitric  acid  diluted  with  its  own  bulk  of  water,  upon  commercial  zinc  in 
excess.  The  filtered  liquid  is  evaporated  by  a  gentle  heat  until  a  slight 
ebullition  is  produced,  which  shows  that  the  necessary  point  of  concentra- 
tion is  reached;  and  the  liquid  is  allowed  to  cool. 

For  a  paste  analogous  to  Canquoin's  take  2  parts  of  saturated  solution 
and  about  1  part  of  flour. 

Oxide  of  zinc. — The  oxide  and  carbonate  are  used  externally  in  oint- 
ment or  powder,  for  chancrous,  fetid,  etc.,  ulcers,  fissures  of  the  breast  and 
lips,  intertrigo  of  children,  chronic  ophthalmia,  and  coryza;  suspended  in 
mucilaginous  water,  they  are  used  for  leucorrhoea,  blennorrhagia,  etc.,  etc. 
The  amount  used  is  nearly  unlimited. 

Sidphate  of  zinc. — The  sulphate,  carbonate,  oxide  and  acetate  of  zinc 
have  been  used  internally  as  antispasmodics.  But  all  of  these  have  been 
chiefly  used  as  local  remedies,  and  all  fulfil  nearly  the  same  indications; 
though  the  soluble  preparations  are  in  general  very  irritating,  and  must 
only  be  ordered  in  very  small  doses,  while  the  carbonate  and  oxide  may 
be  used  in  much  larger  doses. 

Sulphate  of  zinc  internally  is  used  only  as  an  emetic,  which,  accord- 
ing to  the  exjjeriments  of  M.  Toulmouche,  of  Rennes,  is  more  certain  than 
tartar  emetic,  and  may  be  compared  with  sulphate  of  copper.  It  is  given 
for  this  purpose  in  the  dose  of  40 — 75  centigrammes  (gr.  6 — 12)  dissolved 
in  100 — 125  grammes  (  3  iii. — iv.)  of  water.  This  is  much  used  by  our 
neighbors  beyond  the  water,  and  perhaps  we  should  do  well  to  imitate 
them;  it  is  especially  adapted  to  cases  of  poisoning,  as  it  produces  vomit- 
ing more  promptly  and  much  more  surely  than  tartrated  antimony:  in  this 
case  it  is  given  in  a  somewhat  larger  dose  than  that  just  mentioned;  and, 
if  the  poison  is  a  narcotic,  twice  or  three  times  as  much  should  be  given. 

Aran,  following  Baly,  recommends  sulphate  of  zinc  as  useful  in  the 
constipation  of  nervous  persons. — Sulphate  of  zinc,  ^  gramme   (gr.  4); 


250  THERAPEUTICS. 

bread-crumbs,  q.  s. ;  f.  pil.  xii.  and  silver  them.  One  pill  directly  after 
eating;  from  3  to  5  a  day,  or  more. 

Sulphate  of  zinc  is  given  very  often  externally.  In  acute  and  chronic 
catarrh  of  the  mucous  membranes,  it  is  useful  to  place  it  in  contact  with 
the  diseased  surfaces.  In  conjunctivitis,  nasal  catarrh,  and  urethritis,  it 
is  used  in  the  proportion  of  from  1  to  10  or  20  centigrammes  (grs.  0*15 — 
3)  to  30  grammes  (8  ounces)  of  distilled  water;  in  leucorrha^a,  it  is  injected 
in  the  dose  of  2 — 8  grammes  (grs.  30 — 120)  to  500  of  water  (1  pint);  the 
same  in  gargles  for  chronic  throat  complaints. 

Lasegue  gives  it  as  an  injection  in  dysentery — 3  grammes  to  250  of 
water  (gr.  45 —  3  viii.);  he  calls  this  his  intestinal  collyrium.  , 

A  one  per  cent,  solution  of  the  sulphate  is  by  far  the  best  local  rem- 
edy for  blennorrhagia  after  the  acute  stage.  It  may  be  given  when  the 
discharge  ceases  to  be  purulent,  and  becomes  mucous  and  catarrhal.  This 
may  be  recognized  by  the  fact  that  while  purulent,  the  discharge  is  not 
adhesive;  but.  as  soon  as  it  becomes  mucous,  it  sticks  to  a  piece  of  cloth, 
and  may  be  drawn  out  in  a  thread,  of  a  length  proportioned  to  the  amount 
of  mucus  present. 

A  cloth  is  not  always  necessary,  for  when  the  patient  uncovers  his 
glans  the  liquid,  adhering  to  the  prepuce,  may  form  one  or  more  threads 
of  mucus.  We  can  then  say  that  recovery  is  not  distant,  and  may  soon 
be  attained  by  the  use  of  sulphate  of  zinc.  The  same  phenomenon  may 
be  noticed  at  the  close  of  purulent  ophthalmia  in  children  or  adults. 

It  is  added  to  baths,  in  the  amount  of  60 — 120  grammes  (nearly  2 — 4 
ounces)  to  relieve  the  itching  caused  by  prurigo,  chronic  eczema,  and,  in 
general,  by  the  herpetic  affections. 

Sulphate  of  zinc,  closely  united  with  alum,  by  fusion  in  a  porcelain 
capsule,  was  lately  presented  by  Dr.  Richard  of  Soissons,  as  one  of  the 
most  prompt  and  certain  means  of  relief  for  pruritus  pudendi;  as  these 
substances  are  both  valuable  when  used  separately,  we  may  believe  tliat 
when  combined,  they  acquire  a  still  higher  efficacy.  They  form  a  new 
remedy,  not  to  be  neglected  in  so  troublesome  and  often  obstinate  a  com- 
plaint. 

Acetate  of  zinc  is  never  used  internally.  Externally,  it  has  exactly 
the  same  use  as  the  sulphate.  Dr.  Pujet  employs  the  solution  as  a  topic, 
giving  it  in  baths,  or  leaving  it  in  contact  with  the  skin  for  one  or  sev- 
eral hours. 

Zinc,  exposed  to  the  air  and  used  for  roofing  or  gutters,  forms  with 
the  rain  only  a  small  amount  of  an  insoluble  salt;  and  the  same  is  true 
of  the  tanks  of  zinced  iron  which  are  used  in  the  navy.  The  water  kept 
in  such  tanks  is  very  limpid,  and  that  collected  on  zinc  roofs  is  also  very 
healthy  (Bouchardat  and  Fonssagrives,  Bull,  de  ther.^  1864,  t.  LXYIL,  p. 
70). 

For  Valerianate  of  zinc,  see  Valerian, 


IliKITANTS,  251 


Copper. 


Metallic  copper  is  no  longer  vised  in  medicine ;  a  few  salts  repre- 
sent it,  namely:  ammoniated  copper,  the  diacetate,  the  subacetate,  and 
the  sulphate. 

Ammoniated  copper. — This  is  mostly  used  externally,  yet  it  has  been 
given  by  some  for  epilepsy  in  the  dose  of  10-50  centigrammes  (gr.  iss. — 
viii)  daily.  It  is  regarded  by  Dr.  Mercy,  physician  to  the  Children's' Hos- 
pital at  Pesth,  as  an  almost  infallible  specific  for  St.  Vitus'  dance.  He 
combines  40  centigrammes  (gr.  6)  of  the  salt  with  100  grammes  (  3  xxv.) 
of  mint-water  and  about  30  grammes  (  §  i.)  of  simple  syrup,  to  which  he 
adds  G  or  8  drops  of  tincture  of  opium,  to  assist  toleration.  A  child  of  six 
years  receives  of  this  two  teaspoonfuls  four  times  a  day,  which  dose  is  rap- 
idly increased,  if  the  stomach  bears  it,  till  40  centigrammes  of  ammoniated 
copper  (gr.  6.)  are  taken  daily.  He  states  that  among  more  than  200 
cases  he  has  almost  always  seen  the  chorea  depart  so  quickly  that  the  re- 
lation of  cause  and  effect  has  been  unmistakable. 

Placed  in  contact  with  the  skin  and  mucous  membranes,  it  causes  a 
violent  irritation. 

It  forms  the  ean  celeste  so  much  praised  in  the  treatment  of  chronic 
ophthalmia,  for  which  purpose  it  is  used  in  the  proportion  of  a  few  drops 
to  the  ounce  of  distilled  water,  increasing  the  proportion  as  the  sensibil- 
ity of  the  conjunctiva  diminishes.  It  has  been  of  equal  use  in  blennor- 
rhagia,  leucorrhoea,  and  chronic  ulcers.  M.  Cullerier  makes  a  mixture 
of  28  grammes  of  ammoniated  copper  with  4  of  nitrate  of  mercury  to 
touch  venereal  ulcers  which  resist  mercury. 

It  is  not  used  internally;  externally  it  forms  an  ingredient  of  a  great 
many  ointments  and  powders,  formerly  of  much  celebrity  in  the  treatment 
of  ulcers  and  chronic  diseases  of  the  skin.  Dissolved  in  water  in  various 
proportions,  it  is,  like  the  sulphate,  of  which  we  shall  presently  speak, 
useful  in  chronic  ophthalmia,  blennorrhagia,  syphilitic  or  simple  ulcers, 
dartres,  and  especially  eczematous  dartres. 

Subacetate  of  copper,  verdigris  of  commerce  (a?s  viride,  viridis  reris, 
gerugo  rasilis)  shares  all  the  poisonous,  irritant,  purgative  and  therapeu- 
tic properties  of  the  diacetate  of  copper. 

In  pharmacy  it  is  used  in  a  multitude  of  plasters  and  salves,  which  are 
not  without  use  in  external  diseases. 

It  has  been  given  internally.  It  formed  the  essential  element  of  the 
famous  Gerbier's  cancer-pills,  which  cured  some  patients  as  long  as  the 
composition  remained  secret,  but  have  been  found  completely  inefficacious 
by  experience.  It  has  been  recommended  in  rickets  and  scrofula,  but  the 
facts  are  so  inconclusive  that  we  pass  over  them. 

Sulphate  of  copper  is  a  very  powerful  irritant  poison.  It  forms  the 
most  certain  emetic  we  know  of,  in  the  dose  of  25 — 40  centigrammes  (gr. 
4 — 6).     It  has  been  thought  especially  valuable  as  an  emetic  in  croup. 


252  THERAPEUTICS. 

The  recent  observations  of  MM.  Godefroy  and  Mavel  would  seem  to  show 
that  the  frequent  use  of  a  solution  of  sulphate  of  copper  is  very  rapidly 
beneficial  in  malignant  angina.  A  spoonful  is  given  every  ten  minutes 
of  a  solution  containing  10  centigrammes  in  125  grammes  of  distilled  water 
(gr.  1^ —  3  i^-)*  ^^^  have  seen  two  very  severe  cases  where  we  thought 
the  disease  had  been  cured  by  this  remedy. — We  consider  this  a  case  of 
substitutive  medicine,  like  the  use  of  calomel,  alum,  or  nitrate  of  silver. 

We  have  lately  given  sulphate  of  copper  in  tlie  dose  of  ^ — 1  gramme 
in  an  injection  for  chronic  diarrhoea,  and  we  often  find  it  very  useful,  in 
very  much  the  same  way  as  nitrate  of  silver  is.  The  solution  of  sulphate 
of  copper  is  also  used  (2  grammes  to  500  of  water)  for  catarrhal  leucor- 
rhoea;  injected  morning  and  evening. 

The  sulphate,  as  a  colh^rium,  is  used  in  the  proportion  of  0*05  to  30 
grammes  (^  of  1  per  cent.);  it  is  still  prescribed  under  the  name  of  eau 
celeste  or  pierre  divine. 

Diacetate  of  copper  (deutacetas  cupri,  crystallini  veneris)  when  in  con- 
tact with  a  mucous  membrane,  or  the  skin  deprived  of  its  epidermis,  pro- 
duces a  very  active  irritation:  it  is  a  very  powerful  poison. 


Antimony. 

Antimonial  ointment  is  rarely  used  as  a  revulsive  for  two  reasons:  the 
inflammation  cannot  be  restricted  to  the  superficial  part  of  the  skin,  and 
it  leaves  horrible  scars.  The  application  is  made  upon  the  chest;  and 
when  the  patient  is  a  little  girl,  we  leave  upon  her  a  mark  which  she  may 
find  very  undesirable. 

Sebaceous  cysts. — The  attempt  has  lately  been  made  to  cure  these 
without  a  visible  scar  b}'  tartrated  antimony.  The  disease  is  innocent, 
but  is  almost  always  seated  in  some  exposed  part,  usually  the  head  or 
face.  The  patient  is  urgent  in  his  request  to  be  relieved  of  the  disfigure- 
ment— but  he  also  insists  on  being  cured  without  risk  and  without  a  no- 
ticeable scar,  since  otherwise  the  remedy  might  be  worse  than  the  dis- 
ease. Caustics  may  be  used  without  danger;  we  have  given  directions 
for  the  use  of  Vienna  paste,  sulphuric  acid,  nitric  acid,  chromic  acid,  chlo- 
ride of  zinc. 

One  of  the  simplest  methods  of  using  tartarized  antimony  has  been 
popularized  by  M.  Boeckel.  The  method  consists  in  injecting  a  solution 
of  one  part  in  30  of  the  salt  into  the  tumor  with  a  Pravaz  syringe.  When 
the  tumor  is  not  larger  than  a  hazel-nut,  he  punctures  it  with  the  needle 
of  the  syringe,  turning  the  latter  about  so  as  to  divide  any  septa  that 
may  exist;  then,  if  very  sure  that  the  point  is  in  the  cyst,  he  injects 
about  one  gramme  of  the  solution  (gr.  15).  It  is  necessary  to  avoid  pier- 
cing entirely  through  the  cyst,  as,  if  the  fluid  were  injected  into  cellular 
tissue,  it  might  cause  a  phlegmon. 

When  the  injection  is  well  performed,  and  we  are  sure  that  no  fluid 


IRRITANTS.  253 

has  passed  into  the  connective  tissue,  the  tumor  seems,  directly  after- 
wards, to  be  increased  in  bulk.  The  opening  then  cicatrizes.  On  the 
next  day,  and  afterwards,  the  skin  over  the  cyst  is  slightly  reddened,  and 
the  inflammation  increases  until  the  third  day.  On  the  fourth  or  fifth 
day  the  puncture  opens  again  and  discharges  a  small  quantity  of  pus 
mixed  with  a  little  blood  and  more  sebaceous  matter.  On  pressing  the 
tumor,  the  contents  are  easily  pressed  out;  the  entire  sac,  when  it  does 
not  come  out  easily,  is  grasped  with  a  forceps  or  hook.  A  little  pus  es- 
capes for  two  da^'s  more,  and  on  the  eighth  day  all  is  healed. 

The  author  of  the  treatment  faithfully  records  the  accidents.  In  one 
case,  where  the  tumor  was  seated  at  the  le\^l  of  the  eyebrow,  the  cellular 
tissue  of  the  lid  was  inflamed  and  several  incisions  had  to  be  made.  In 
two  other  cases  the  pouch  did  not  come  out,  but  the  improvement  was 
considerable  (Greuell:   "These  de  Paris,"  No.  359,  1872). 


Mustard. 

Two  species  of  mustard,  the  white  and  the  black,  have  been  used  in 
medicine;  the  white  is  preferred  for  internal  use,  the  black  almost  exclu- 
sively for  external  use. 

W7iite  nitistard,  sinapis  alba. — When  a  remedy  is  popular,  when 
quacks  have  long  used  it,  and  always  with  advantage,  it  must  have  some 
valuable  properties,  which  the  obstinacy  or  ill-humor  of  physicians  may 
deny  in  vain. 

The  use  of  mustard-seed  in  medicine  goes  back  nearly  to  the  last  cen- 
tury; Cullen  states  it  most  positively  ("Mat.  med.,"  t.  II.,  p.  180);  he 
used  it  as  a  laxative.  Maccartan,  an  Irish  physician  residing  at  Paris, 
published  in  the  Journal  general  de  medecine  (t.  XXXIV.,  p.  72,  1809)  a 
paper  on  its  therapeutic  properties;  this  had  no  influence  on  practice, 
because  his  facts  would  not  stand  examination.  Nevertheless,  in  England 
and  North  America  the  use  of  white  mustard-seed  had  become  popular, 
and  a  few  years  later  it  was  so  in  France.  From  our  own  observations 
we  can  state  that  this  is  a  very  useful  remedy. 

Cullen  remarked  its  laxative  effect.  It  purges  in  the  dose  of  30  to  45 
grammes  (  3  i. — iss.).  It  is  given  whole,  on  a  fasting  stomach,  at  bedtime 
or  just  before  eating.  The  dose  varies  with  each  person,  but  should  be 
sufficient  to  procure  one  or  two  easy  evacuations  daily. 

This  kind  of  purgation  causes  no  colic,  and  is  of  especial  use  to  those 
who  are  habitually  constipated,  and  whose  digestion  is  laborious.  We 
have  found  it  especially  useful  to  those  suffering  with  piles.  The  physi- 
cian must  decide  whether  this  digestive  torpor  depends  on  inflammation, 
in  which  case  the  use  of  white  mustard-seed  would  not  be  indicated. 

Popular  opinion  ascribes  its  chief  virtue  to  its  depurative  function. 
The  question  must  be  examined,  first  by  experiment,  next  by  theory. 
All  the  evidence   shows  (and  our  own  experience  does  not  permit  us  to 


254  THERAPEUTICS. 

doubt  it)  that  this  substance  has  a  very  powerful  depurative  action; 
cutaneous  diseases  and  chronic  rheumatisms,  which  nothing  could  benefit, 
have  been  cured  or  placed  in  a  way  to  be  cured  by  the  long-continued 
use  of  white  mustard-seed.     This  fact  is  to  be  explained  as  follows: 

Must  not  the  permanent  irritation  of  the  surface  of  the  digestive 
mucous  membrane,  producing  as  it  does  a  continual  secretion  of  mucus, 
be  considered  as  a  derivative  act,  and  may  we  not  explain  the  disappear- 
ance or  diminution  of  a  disease  by  this  derivation  alone  ?  This  view 
seems  to  us  the  more  reasonable,  as  frequent  purgation  has  been  regarded 
by  all  pliysiciaus  as  an  efficient  treatment  of  chronic  diseases  of  the  skin. 
And  again:  if  we  remember  that  mustard-seed  only  keeps  the  bowels 
a  little  relaxed  without  causing  active  irritation  of  the  mucous  mem- 
brane, and  that  drastic  purgatives,  though  they  stimulate  that  surface 
much  more  actively,  do  not  cure  dartres  and  rheumatisms  so  surely,  we 
shall  be  forced  to  infer  that  there  is  in  mustard,  as  in  most  other  cruci- 
ferjB,  an  active  principle  which  probably  modifies  the  blood  and  conse- 
quently the  whole  system.  Perhaps  this  active  principle  is  only  sulphur, 
which  is  known  to  exist  in  a  considerable  proportion  in  all  the  plants  of 
this  family. 

Whatever  be  the  explanation  (we  do  not  attach  much  importance  to 
our  hypothesis),  we  appeal  to  the  facts  alone,  and  call  attention  to  a 
remedy  which,  because  too  well  known,  is  too  little  appreciated. 

From  the  seed  of  sinapis  alba  are  made  most  of  the  mustards  eaten  at 
table.  This  article,  well  appreciated  by  old  men  and  by  persons  whose 
digestion  is  sluggish,  is  unjustly  condemned  by  certain  physicians.  It  is 
certainly  not  appropriate  to  those  who  digest  laboriously,  as  they  have  an 
acute  or  subacute  gastritis;  but  in  certain  chronic  forms  of  gastritis,  in  a 
great  many  gastralgias,  and  in  general,  in  those  affections  of  the  diges- 
tive tube  in  which  the  muscular  layer  is  evidently  inert,  and  the  normal 
secretions  of  the  mucous  membrane  are  almost  entirely  suppressed,  mus- 
tard, taken  from  time  to  time,  is  of  use,  and  becomes  almost  a  necessary 
condition  of  good  digestion. 

Black  mustard  (sinapis  nigra)  is  most  commonly  used  externally. 
It  is  ground,  and  used  in  sinapisms,  cataplasms,  mustard-baths,  etc.  It 
is  one  of  the  most  common  remedies;  and  yet  its  mode  of  action  is  not 
generally  well  known. 

In  almost  all  the  books  on  materia  medica,  in  the  majority  of  articles  in 
dictionaries,  we  are  struck  with  the  discrepancies  between  authors.  Some 
recommend  mixing  with  warm  water  or  warm  vinegar  indifferently; 
others  prefer  vinegar  or  concentrated  acetic  acid,  to  produce  a  more  active 
effect.  Some  expressly  direct  the  choice  of  freshly  ground  meal;  others 
direct  only  the  use  of  the  bran.  As  regards  the  period  of  application, 
some  have  it  four  hours  in  contact  with  the  skin,  some  two  or  three 
hours,  others  an  hour  or  an  hour  and  a  half. 

What  are  the  readers  of  books  to  do  ? — Not  knowing  how  to  decide, 
we   did  what  we  might   have   done  at  the  beginning;  before  writing  we 


IRRITANTS.  255 

made  experiments,  and  we  shall  now  give  their  results.  They  were  made 
in  1829  and  published  in  1830,  and  confirm  the  chemical  results  of  M. 
Faure  and  the  more  recent  ones  of  M.  Boutron. 

1st  question  : — Should  the  mustard  be  freshly  ground,  or  long 
ground  ?  , 

We  mixed  two  portions  of  mustard  in  cold  water.  One  had  been 
ground  a  week,  and  kept  in  a  closed  box;  the  other,  five  months,  and  kept 
in  a  paper  bag  in  a  damp  chest  of  drawers.  The  two  were  applied  to  the 
right  and  left  thigh  respectively. 

Fresh  Mustard.  Old  Mustard. 

After  4^  rain. ,  slight  prickling,  4^  min. ,  no  sensation. 

5  min.,  a  little  heat,  slight  throbbing  syn-  5  min.,  no  sensation, 
chronous  with  pulse. 

6  min.,  lively  smarting.  6  min.,  slight  prickling. 

7  min.,  smarting  increases.  7  min.,  slight  smarting. 

8  min.,  smartiuf,'  very  intense.  8  min.,  smarting  lively,  arterial  pulsation. 

9  min.,  the  pain  becomes  deeper;  sensation  9  min.,  sensation   of   burning;    pain  be- 
of  weight  in  the  part  in  contact  with  comes  deeper. 

mustard. 

10  min.,  sensation  of  heat  and  burning;      10  min. ,  sensation  the  same  as  in  the  other 
very  hot.  leg. 

The  experiment  always  gave  the  same  result.  Old  flour  acted  at  the 
end  of  ten  minutes  exactly  in  the  same  way  as  new,  though  it  began  to 
act  much  more  slowly.  There  is,  then,  no  remarkable  difference  between 
black  mustard  ground  a  week  and  that  which  has  been  ground  five 
months. 

2d  Question. — Does  a  sinapism  prepared  with  hot  water  act  more 
quickly  than  one  prepared  with  cold  water  ? 

"VVe  applied  two  sinapisms,  one  prepared  with  water  at  40°  (104°  F.), 
and  the  other  with  water  at  15°  (59°  F.), 

Cold  icater. — See  the  first  experiment. 

Warm  water. — Two  minutes,  slight  sensation;  3,  a  little  smarting; 
4,  acute  smarting,  slight  arterial  throbbing;  5,  painful  smarting,  throb- 
bing very  perceptible,  pain  more  profound  ;  5|-,  pain  very  acute  and  vio- 
lent; 7,  pain  no  longer  sensibly  increasing;  afterwards  it  becomes  more  pro- 
found; the  arterial  throbbing  is  less  energetic;  10  minutes,  same  condition. 

We  see  that  the  one  which  was  prepared  with  warm  water  acts  much 
more  quickly  than  the  cold  one.  But,  after  all,  at  the  end  of  ten  minutes 
the  effects  are  exactly  alike.  This  is  easily  understood,  since  the  time  is 
sufficient  to  enable  the  temperature  of  the  skin  and  the  sinapism  to  be- 
come equal. 

We  do  not  conclude  that  it  is  indifferent  whether  we  apply  it  warm  or 
cold:  the  sensation  of  a  cold  body  applied  to  the  skin  must  certainly  in 
certain  cases  be  injurious.  But  the  temperature  of  the  application  is  so 
speedily  equalized  with  that  of  the  skin,  and  the  blood  comes  so  quickly 


256  THERAPEUTICS. 

to  the  derma,  that  we  regard  the  fears  entertained  by  some  therapeutists 
as  greatly  exaggerated.  But  it  is  important  to  add  that  if  the  sinapism 
had  been  prepared  with  boiling  water  instead  of  water  at  40°,  it  would 
certainly  have  lost  its  irritating  power. 

3d  Question. — Does  mustard  flour  mixed  with  vinegar  act  with  more 
pd*wer  than  that  mixed  with  water  ? 
Water. — See  first  experiment. 

Vinegar. — Fifteen  minutes,  slight  smarting;  twenty,  smarting  a  little 
increased,  but  hardl}^  appreciable;  twenty -five,  it  becomes  a  little  more 
active;  fifty,  a  little  more  decided,  nearly  equivalent  to  that  which  the 
sinapism  made  with  water  causes  at  the  end  of  six  minutes. 

This  experiment  was  made  several  times  upon  different  persons,  and 
gave  constant  results.  Comparing  the  time  required  to  produce  a  cer- 
tain result,  we  might  say  that  the  degree  of  activit}^  of  the  one  is  to  that 
of  the  other  as  6  to  50,  or  1  to  8. 

In  these  experiments  the  vinegar  was  cold.  Wishing  now  to  ascertain 
whether  warm  vinegar  acted  more  energetically,  we  made  the  experiment, 
but  found  an  entirely  negative  answer. 

AVisliing  to  see  whether  the  dilution  of  the  fluid  (table  vinegar)  used 
in  these  experiments  might  have  affected  the  results,  we  now  mixed  the 
mustard  flour  with  equal  })arts  of  water  and  concentrated  acetic  acid,  and 
obtained  the  following  result: 

We  left  the  sinapism  45  minutes  in  cojitact  with  the  skin,  without 
producing  the  least  sensation  of  stinging. 

Finalh',  we  prepared  two  sinapisms,  one  with  concentrated  acetic  acid, 
and  the  other  with  water.  The  results  are  so  extraordinary  that  we  place 
them  side  by  side. 

Water.  Concentrated  Acetic  Acid. 

6  min.,  slight  prickling-.  6  min.,  nothing. 

7  min.,  active  stinging.  7  min. .  moderate  stinging. 

8  min.,  active  stinging  and  arterial  pulsa-    8  min.,  stinging  a  little  increased, 
tions. 

9  min.,  sensation  of  burning.  9  min.,  pain  less  than  in  the  other  sina- 

pism. 

10  min.,  very  painful  ;  removed.  10  min.,  stinging  rather  sharp;     light  ar- 

terial pulsations. 

11  min.,  stinging  painful ;  sensation  differ- 
ent from  that  produced  by  the  other. 

13  min.,  sensation  of  burning;  removed. 

One  would  hardly  have  supposed  a  priori  that  concentrated  acetic  acid 
Avould  act  with  less  energy  than  water  in  a  sinapism. 

Having  seen  that  concentrated  acetic  acid  had  almost  no  activity 
vv^hen  mixed  with  mustard,  we  were  curious  to  know  if  a  cataplasm  made 
of  sawdust  with  the  same  acid  would  be  more  active  than  the  sinapism; 
in  consequence,  we  made  a  paste  of  the  acid  and  the  dust  of  our  writing- 


IRRITANTS.  257 

desk,  and  applied  it  upon  our  own  leg.  In  a  minute  and  a  half  acute 
stinging  was  felt;  in  two  minutes  the  pain  was  severe;  half  a  minute  later 
it  was  insupportable,  and  in  three  minutes  it  was  so  violent  that  we  were 
forced  to  remove  the  application;  but  the  skin  was  severely  cauterized. 

Mustard,  therefore,  when  mixed  with  water,  acts  more  energetically 
than  when  mixed  with  common  vinegar,  weak  or  strong  acetic  acid;  and 
acetic  mixed  with  mustard  loses  some  of  its  efficacy.  The  mustard  is  weak- 
ened by  the  acid,  and  the  acid  by  the  mustard. 

If  we  wish  to  produce  active  rubefaction  and  even  a  superficial  burn 
of  the  skin,  it  is  sufficient  to  place  acetic  acid  for  three  minutes  in  con- 
tact with  the  skin,  in  a  sponge  or  some  inert  powder;  and  certainly,  no 
sinapism  will  act  so  speedily.  But  if  we  want  a  sinapization,  that  is,  a 
modification  of  the  skin  which  pi'oduces  a  si/uipic  sensation,  redness  and 
swelling  (the  expression  is  exact),  we  require  mustard  and  water.  And 
when  we  wish  to  mitigate  a  sinapism,  instead  of  adding  flaxseed,  bread- 
crumb, or  yeast,  it  is  sufficient  to  prepare  it  with  vinegar. 

All  the  vinegar-makers  in  the  world  teach  their  apprentices  the  art  of 
correcting  the  sting  of  mustard  with  vinegar;  the  useful  lesson  has  not 
been  lost  on  everybod3\  Aetius  insisted  on  the  point  when  he  said  : 
"  Sed  et  hoc  noscendum  est:  si  in  aceto  maceretur  sinapi,  inefficacius 
redditur;  acetum  enim  sinapio  vim  discutit  "  ("  Aetii  de  atrabili,  sermo 
tertius.  Sinapismi  pr;x?paratio").  Schwilguc  repeated  it  in  his  "  Traite  de 
matiere  medicale,"  and  it  was  long  customary  in  our  hospitals  to  weaken 
sinapisms  with  vinegar.  But  it  is  only  a  little  while  ago  that  the  con- 
trary was  taught  in  all  the  courses  and  the  books;  which  is  our  reason 
for  publishing  these  experiments,  which  have  already  resulted  in  making 
our  physicians  acquainted  with  a  notion  which  we  owe  to  Aetius. 

Before  concluding  what  we  have  to  say  of  sinapisms  made  with  water 
and  vinegar,  we  must  say  that  our  own  experiments  were  made  with  ex- 
cellent black  mustard  flour,  ground  as  it  is  by  all  the  good  druggists  in 
Paris;  the  quality  of  the  flour  need  not  be  questioned,  as  it  causes  almost 
insupportable  pain  in  ten  minutes. 

We  procured  also  some  "  English  flour,"  which  is  sold  for  preparing 
the  fresh  mustard  of  our  tables.  We  mixed  this  with  water,  and  pre- 
pared another  sinapism  with  ordinary  black  mustard,  but  the  action  was 
identical  in  the  two  cases;  then  mixing  with  vinegar,  we  were  no  little 
astonished  to  find  the  results  different  from  the  former  ones,  for  the  ad- 
dition of  vinegar  did  not  so  completely  destroy  their  activity. 

We  are  entirely  ignorant  of  the  cause  of  this  difference.  But  M.  Gui- 
bourt  has  shown  that  the  English  flour  was  not  prepared  with  white  mus- 
tard seed,  but  with  the  black,  and  the  difference  between  the  English  and 
the  French  flour  consisted  in  the  fact  that  the  latter  had  been  passed 
through  a  sieve  with  wider  meshes.  The  only  physical  difference  between 
the  two  is,  that  the  French  kind  is  of  a  dirty  yellow  specked  with  brown, 
while  the  other,  very  finely  ground,  seems  free  from  bran,  and  is  of  a 
uniform  jonquil  color. 

i: 


258  THERAPEUTICS. 

We  prepared  some  sinapisms  with  alcohol,  but  they  were  less  power- 
ful than  those  prepared  with  mustard. 

We  will  now  add  some  remarks  on  the  direct  effects  of  sinapisms,  and 
will  conclude  by  considerations  on  the  means  for  soothing  the  severe  pains 
which  the  application  sometimes  causes. 

We  saw  that  if  the  sinapism  was  prepared  with  good  flour  and  water, 
a  sensation  of  prickling  occurred  at  the  point  of  contact  within  four  or 
five  minutes;  this  became  more  and  more  severe,  and  in  ten  minutes  re- 
sembled the  pain  caused  by  white-hot  iron  held  a  little  way  from  the  skin. 
Almost  intolerable  in  ten  minutes,  it  grows  more  and  more  deep,  and  is 
soon  constrictive  and  gravative,  that  is,  it  gives  the  feeling  of  a  heavy 
body  weighing  on  the  muscles  a,nd  compressing  them.  This  sensation  is 
less  intolerable  than  that  which  preceded  it,  so  that  a  sinapism  can  be 
borne  much  longer  than  would  have  been  supposed  from  the  severity  of 
the  first  pains.  But  when  the  calm,  or  rather  the  change  in  the  charac- 
ter of  the  pains  has  lasted  twenty  or  twenty-five  minutes,  the  sensation 
of  burning  begins  afresh,  more  severe  than  ever,  and  the  most  docile  and 
courageous  patients  rarely  bear  three-quarters  of  an  hour  of  a  well-made 
sinapism  unless  their  sensibility  is  blunted  by  an  idiopathic  or  secondary 
ceiebral  affection. 

When  the  application  is  raised,  the  impression  of  the  cold  air  almost 
wholly  puts  a  stop  to  the  pain.  The  skin  is  not  swollen,  and  there  is 
liardly  any  redness;  but  in  a  few  moments  the  stinging  reappears,  the  skin 
is  dotted  with  red  points,  and  soon  becomes  of  a  uniform  rose  color.  The 
stinging  becomes  more  acute  and  is  at  last  a  burning;  the  least  rubbing- 
exasperates  it,  and  the  impression  of  cold  lessens  it.  However  lively  the 
redness,  there  is  no  very  distinct  swelling,  unless  the  person  is  predis- 
posed to  ojdema.  The  stinging  may  last  twelve  hours,  and  even  a  week; 
it  has  a  special  character,  and  produces,  especially  in  women,  a  nervous 
excitability  which  is  not  always  Avithout  danger.  We  have  seen  women 
suffering  cruel  and  unconquerable  insomnia,  shedding  tears,  and  attacked 
with  quite  severe  nervous  symptoms,  so  acute  were  the  sufferings. 

The  redness  lasts  much  longer  than  the  pain,  and  often  exists  in  a 
high  degree  when  the  stinging  has  almost  entirely  disappeared,  at  the  end 
of  eight  or  ten  days;  but  in  this  ease  an  itching  appears  every  evening, 
which  is  by  no  means  painful,  but  rather  pleasant  to  scratch. 

When  the  sinapisms  have  been  long  applied  and  often  repeated, 
though  they  may  not  have  caused  blisters,  they  may  leave  yellow  spots, 
which  are  sometimes  indelible. 

A  sinapism  must  be  applied  a  longtime  to  produce  vesication;  and 
the  ampullnj  appear  much  later  than  when  cantharides  are  used.  The 
phlycteniu  do  not  rise  all  at  one  time,  so  as  to  form  one  large  bulla,  but 
are  developed  partially  and  successively. 

Such  are  the  effects  of  a  sinapism  prepared  with  water,  on  the  skin  of 
most  persons,  when  applied  not  longer  than  fourteen  or  fifteen  minutes. 
Some  persons  are  less  irritable,  and  resist  the  action  of  mustard;  but  our 


IRRITANTS.  259 

experience  shows  that  it  is  usually  injurious  to  let  it  remain  an  hour;  we 
consider  the  direction  sometimes  given,  to  leave  it  three  or  four  hours  in 
contact  with  the  skin,  as  very  dangerous. 

We  know  a  lady  who,  at  the  age  of  twenty,  had  convulsions  during 
childbirth,  in  consequence  of  which  she  fell  into  a  profound  coma;  the 
physician  bled  her,  and  applied  at  the  same  time  four  sinapisms,  two  on 
the  wrists  and  two  on  the  ankles.  The  mustard  remained  on  but  three 
hours,  and  though  the  patient  gave  no  sign  of  sensibility  during  that 
period,  yet  eschars  were  afterwards  formed,  and  she  nearly  fell  a  victim 
to  the  excessive  activity  of  treatment. 

In  circumstances  like  this  it  is  important  to  know  how  long  a  sinapism 
may  be  applied,  since  when  consciousness  is  suspended  the  remedy  may 
exhaust  all  its  activity  on  the  skin  before  the  brain  is  informed;  and 
when  consciousness  returns,  we  are  surprised  to  hear  the  patient  complain 
of  frightful  pain,  a  symptom  of  profound  lesion  of  the  skin. 

The  same  caution  is  applicable  to  those  febrile  affections  in  which 
the  nervous  centres  are  deeply  involved.  Thus,  in  dothinenteritis  or 
scarlatina,  complicated  with  ataxo-dynamic  symptoms,  etc.,  sinapisms 
are  sometimes  left  on  for  ten  or  twelve  hours,  the  patient  meanwhile 
showing  no  sensibility,  though  the  skin  is  red  and  phlyctena^  are  formed. 
Two  or  three  days  later,  when  the  sensibility  returns,  the  pain  becomes 
insupportable,  and  a  new  fever  is  kindled;  the  skin  becomes  gangi-enous, 
and  in  some  cases  the  remedy  is  accused  of  causing  death. 

We  conclude  that  a  sinapism  prepared  with  water  ought  never  to  be 
left  applied  more  than  one  hour;  that,  even  when  no  complaint  is  made, 
it  must  be  removed  at  that  time;  and  that,  if  we  desire  the  effect  to  be  pro- 
duced slowly,  and  the  mustard  to  remain  applied  for  several  hours,  we 
must  mix  with  vinegai-  in  order  to  moderate  the  activity,  or  change  the 
position  every  quarter  of  an  hour. 

Two  things  have  prevented  physicians  from  understanding  the  degree 
of  activity  which  sinapisms  possess:  first,  the  belief  that  thej-  are  never 
so  active  as  when  made  with  vinegar,  and  second,  the  adulteration  of  the 
remedy. 

Many  pharmacists,  even  in  Paris,  have  no  mill  to  grind  mustard,  and 
buy  it  already  ground,  of  the  wholesale  dealers.  The  latter  sophisticate 
it  in  evei-y  way;  they  add  the  refuse  of  colza  or  flax-seed,  and  a  coloring 
matter.  The  only  reliance  is  to  be  placed  on  mustard  ground  in  the  drug- 
shops.  The  family  and  even  the  physician  do  not  hesitate  to  send  to  the 
next  grocer;  and  we  have  seen  a  poultice  made  from  mustard  thus  bought, 
which  remained  applied  eight  hours  without  causing  the  least  stinging, 
while  the  same  person  felt  insupportable  pain  in  ten  minutes,  when  a 
similar  poultice  of  mustard  ground  by  the  druggist  was  applied. 

Since  this  experience,  we  have  several  times  encountered  accidents 
caused  by  sinapisms  which  were  not  kept  on  over  an  hour.  We  first 
tried  laudanum  and  the  opiates,  applied  to  the  inflamed  skin,  but  this 
hardly  lessened  the  pain,  though  the  dose  was  carried  to  the  point  of 


26C>  THERAPEUTICS. 

producing-  intoxication.      A  much  more  successful  application  was  found 
to  be: 

Unguent,  populeum, 15  grammes  (  3  ss.). 

Extr.  belladonniis,  ) 

"    hyoscyami,    r aa     0*3       "         (gr.  ivss.). 

"    stramonii,      ' 

A  thin  layer  of  this  is  to  be  spread  on  a  cloth  and  applied  to  the 
affected  part.     A  cataplasm  composed  as  follows  is  equally  useful : 

Belladonna,  leaves  and  stalks,  ) 

Hyoscyamus,    "  "      r aa  8  grammes  (  3  ii-)* 

Stramonium,     "  ' 

Boil  in  1,000  grammes  (1  quart)  of  water  till  reduced  to  one-half;  make 
poultices  with  bread-crumb  or  flax-seed  meal  mixed  with  the  decoction. 

The  "  baume  tranquille"  may  also  be  used  to  anoint  with;  but  alco- 
holic liquors,  such  as  laudanum,  cause  extremely  severe  pains. 

If  the  skin  is  severely  excoriated,  these  narcotics  may  cause  vertigo 
and  somnolence;  the  dose  must  then  be  lessened,  in  proportion  to  the  ex- 
tent of  the  denuded  surface. 

As  for  the  special  conditions  which  demand  the  use  of  sinapisms,  we 
shall  speak  of  them  in  the  chapter  on  Irritant  Treatment,  where  their 
effects  will  be  studied  by  comparison  with  those  of  other  agents. 


Ca.ntiiakides. 
Physiolofjicid  Action . 

^'arious  insects  of  the  class  cantharis  contain  cantharidin,  which  is 
really  the  only  vesicating  principle  that  they  do  contain.  But  as  the 
officinal  cantharis  is  the  only  one  generally  employed,  we  will  take  it  as 
the  type. 

Cantharides  in  powder,  and  the  numerous  preparations  which  retain 
the  active  principle,  are  very  dangerous  poisons.  Cases  of  poisoning  are 
frequently  produced  by  this  substance,  whether  given  to  excite  the  vene- 
real orgasm,  or  to  provoke  abortion.  The  ingestion  of  cantharides,  in 
addition  to  the  gastric  symptoms  which  are  common  to  all  acrid  poisons, 
produces  special  nervous  symptoms,  as  somnolence,  delirium,  slowness  of 
circulation,  and  an  excitement  of  the  genital  organs  which  is  sometimes 
excessive. 

Placed  in  contact  with  the  skin,  the  powder  of  cantharides  produces 
in  a  few  hours  a  feeling  of  numbness  which  is  at  first  hardly  painful,  but 
afterwards  becomes  a  sense  of  painful  pressure,  and  then  of  burning. 
The  suffering  is  rarely  acute,  except   the   patient  makes  a  good   deal   of 


IRRITANTS.  261 

movement  and  irritates  the  denuded  papilla?.  After  a  time,  the  length 
of  which  depends  on  a  great  many  circumstances,  the  epidermis  is  raised 
by  small  builse  filled  with  serum,  though  the  skin  is  not  very  red.  After- 
wards, if  the  action  is  continued,  the  bulla?  unite  and  form  a  single 
phlyctena.  When  removed,  it  discovers  a  layer  of  half-coagulated 
lymph  on  the  surface  of  the  skin,  easily  separated,  and  usually  repeated 
after  each  dressing,  so  as  sometimes  to  form  a  very  plastic  and  thick  layer. 

These  false  membranes  are  easily  raised  at  the  first  dressings,  but 
afterwards  they  become  more  and  more  adherent,  and  at  last  form  a  sort 
of  artificial  epidermis  which  dries,  and  under  which,  after  a  few  days,  is 
found  a  delicate  red  epidermis  like  that  of  a  fresh  cicatrix.  In  other 
cases,  when  the  action  has  not  been  energetic,  no  appreciable  false  mem- 
branes are  formed,  but  the  epidermis  is  reformed  directly  from  a  layer  of 
the  liquor  exhaled  from  the  skin,  which  seems  to  dry  at  contact  with  the 
air. 

Besides  this  topical  action,  there  is  a  general  one,  due  on  the  one 
hand  to  the  inflammation  of  the  skin,  however  slight  its  intensity  may  be; 
on  the  other,  to  the  resorption  of  an  irritant  element  which  circulates  in 
the  blood  and  stimulates  the  different  tissues  of  the  system.  This  fact 
of  absorption  is  well  known  by  symptoms  referred  to  the  kidneys,  blad- 
der, and  generative  organs;  perhaps,  also  these  accidents  form  a  partial 
cause  of  the  general  reaction  of  which  we  lately  spoke. 

On  the  part  of  the  urino-genital  system,  the  symptoms  are  commonly 
slight,  unless  the  blister  be  extremely  large,  or  cantharides  have  been 
swallowed.  They  usually  consist  of  an  increase  in  the  quantity  of  urine, 
and  in  the  frequency  with  which  it  is  passed — a  frequency  out  of  propor- 
tion to  the  amount  passed; — in  men,  there  is  heat  in  urinating,  with  a 
tendency  to  erection;  in  women,  a  much  more  marked  burning,  and  rare- 
ly erotic  erethism.  These  slight  disorders  are  not  spoken  of  by  the  pa- 
tient unless  his  attention  is  called  to  them;  but  when  the  person  is  irri- 
table, or  has  taken  a  great  quantity  of  the  drug,  or  the  blister  has  been 
too  large,  or  applied  to  a  recently  scarified  surface,  the  symptoms  have  a 
form  and  intensity  which  cannot  be  concealed.  Thus,  there  is  suppres- 
sion or  retention  of  urine,  with  a  spasm  of  the  urethra  which  the  sound 
cannot  always  overcome;  acute  cystitis  or  nephritis;  painful  priapism, 
which  may  become  inflammation,  and  even  gangrene  of  the  penis;  insa- 
tiable nymphomania,  acute  metritis,  etc.;  but  most  frequently,  symp- 
toms lying  between  those  just  described  and  those  named  before.  Bouil- 
laud  and  Morel-Lavallce,  have  lately  proved  that  an  albuminous  secretion 
mingles  with  the  urine,  under  the  influence  of  a  large  blister,  which  may 
easily  be  proved  by  nitric  acid.  Fibrine,  also,  is  secreted,  and  is  some- 
times condensed  as  a  false  membrane  in  the  bladder,  and  sometimes  is 
found  at  the  bottom  of  the  urinal. 

We  shall  consider  cantharides  chiefly  as  an  agent  for  producing  vesica- 
tion; and  shall  give  from  our  own  experience  some  directions  for  dress- 
ing the  blister  and  relieving  the  symptoms  which  sometimes  appear. 


262  TIIEKAPEUTICS. 

If  we  desire  only  a  flying-blister,  the  application  must  last  only  long- 
enough  to  raise  the  skin,  a  time  which  varies  according  to  the  prepara- 
tion used,  the  nature  of  the  patient's  skin,  the  disease — in  short,  a  multi- 
tude of  circumstances,  which  must  always  be  taken  into  account. 

As  soon  as  the  blister  is  formed,  the  vesicant  is  removed,  and  at  the 
lowest  point  an  opening  is  made  with  scissors,  so  as  to  let  the  serum  es- 
cape. The  epidermis  will  then  be  exactly  in  contact  with  the  chorion,  so 
that  the  pain  will  be  less  at  first,  and  the  healing  much  quicker.  The 
part  is  then  covered  with  a  compress  or  piece  of  wadding  spread  with 
cerate  and  held  by  a  proper  bandage;  this  dressing  is  renewed  twice  a 
day,  till  the  exudation  of  serum  is  at  an  end. 

We  have  seen  the  following  dressing  used  with  success: 

Starch 35  grammes  (  3  ix.). 

Water 35  " 

Glycerine 230  "  (3  Iv.). 

Mix  the  water  and  the  starch,  add  the  glycerine,  and  stir  over  a  fire 
to  the  consistency  of  a  cerate. 

When  the. blister  is  to  serve  as  an  exutory,  we  leave  the  vesicant  on 
the  skin  several  hours  after  the  blister  is  formed.  The  skin  is  to  be  en- 
tirely removed,  and  the  derma  sponged  to  get  rid  of  the  superficial  layer 
of  fibrin.  The  irritation  of  the  skin  is  such  as  to  require  to  be  lessened 
rather  than  increased;  the  first  dressings  should  not  be  made  with  cerate, 
but  with  butter,  or  any  fatty  body  which  does  not  cause  too  rapid  cicatri- 
zation. Where  a  tendency  to  healing  is  seen,  the  butter  is  replaced  by 
an  epispastic  ointment  or  fabric,  of  cantharides  or  mezereon,  and  so  on 
until  a  new  indication  arises,  observing  the  following  rules.  We  will 
suppose  the  following  cases: 

The  blister  dries  up  or  suppurates  too  freely; 

It  is  covered  with  false  membranes; 

It  is  surrounded  with  a  dartrous  eruption; 

It  is  covered  with  vegetations;    . 

It  causes  dysury. 

A.  The  blister  dries,  or  suppurates  too  freely. — In  certain  persons  the 
blisters  cannot  suppurate,  and  dry  very  rapidly,  though  dressed  with  oint- 
ment active  enough  to  produce  in  other  cases  the  greatest  abundance  of 
suppuration.  Some  of  the  causes  of  this  circumstance  may  be  under- 
stood, but  usually  it  is  impossible  to  do  so,  and  only  the  effects  are  seen. 
Some  persons'  wounds  heal  with  great  ease,  and,  as  it  were,  by  first  inten- 
tion, and  suppuration  is  established  with  the  greatest  difficulty.  Others 
have  what  the  vulgar  call  humors,  and  in  them  the  least  scratch  becomes 
poisoned,  and  suppuration  seems  endless.  In  the  former  class,  blisters 
are  very  hard  to  keep  open;  in  the  latter,  but  little  care  is  needed  to 
maintain  suppuration  a  long  time.  In  old  men,  suppuration  is  very  hard 
to  establish  in  blisters,  which  is  explained  by  the  want  of  vascularity  of 


IKRITANT3.  263 

the  skin  in  advanced  life;  but  it  is  a  stranger  thing,  and  one  which  we 
could  not  believe  till  we  had  repeatedly  seen  it,  that  the  suppuration  is 
perhaps  even  more  difficult  to  maintain  in  young  people  than  in  the  old; 
and  if  we  explained  the  former  case  by  the  deficient  vascularity  of  the 
skin,  we  must  explain  the  latter  by  the  excess  of  plastic  force  in  youth, 
by  virtue  of  which  cicatrization  takes  place  very  rapidly. 

In  any  case,  experience  shows  that  blisters,  citteris  paribus,  should  be 
kept  open  in  old  men  and  children  with  much  more  powerful  applications 
than  those  which  are  suitable  for  adults.  The  activity  of  the  epispastic 
agent  should  be  proportioned  to  the  difficulty  experienced  in  maintaining 
suppuration. 

B.  The  Mister  is  covered  xuith  false  niemhranes. — The  generally  re- 
ceived opinion  is,  that  the  excess  of  cantharidal  inflammation  is  the  cause 
of  this  supersecretiou  of  false  membrane  which  is  observed  so  often  on 
blisters.  It  is  certain  that  the  action  of  cantharides  produces  a  pseudo- 
membranous phlegmasia,  as  shown  by  Bretonneau.  This  physician,  by 
injecting  cantliaridal  ether  into  the  trachea  or  larynx  of  dogs,  caused  a 
membranous  inflammation  very  like  that  of  diphtheria;  a  little  of  the 
same  ether,  when  applied  to  the  mucous  membrane  of  a  dog's  lip,  caused 
a  detachment  of  the  epithelium  in  fifteen  or  twenty  minutes,  and  a  false 
membrane  was  soon  formed  underneath,  which  was  easily  raised,  and  for 
a  day  or  two  was  quickly  renewed. 

We  have  said  enough  to  show  that  the  cantharidal  inflammation  is 
essentially  membranous;  but  does  it  follow  that  the  excess  of  this  inflam- 
mation is  the  cause  of  the  accumulation  of  successive  layers  of  fibrine  ? 
We  do  not  think  so.  In  fact,  if  the  strength  of  the  ointment,  stuff,  or 
paper  be  diminished,  we  find  the  false  membranes  becoming  more  and 
more  adherent,  and  the  blister  drying  up.  The  application  of  cataplasms, 
though  sometimes  recommended  with  the  same  object,  sometimes  softens 
the  false  membranes,  so  that  they  can  be  easily  raised  with  a  spatula,  but 
at  other  times  it  is  quite  insufficient. 

The  treatment  which  succeeds  best  is  directly  opposite  to  this.  When 
the  sore  persists  in  forming  fresh  membranes,  which  become  more  and 
more  adherent,  we  apply  a  new  blister  to  the  spot,  or  a  little  ethereal  ex- 
tract of  cantharides,  and  next  day  we  see  the  false  membrane  raised  as  if 
it  were  epidermis,  and  underneath  it  the  derma,  perfectly  clean.  For 
some  days  there  is  no  tendency  to  form  fibrinous  concretions,  but  the  sore 
retains  an  improved  aspect,  showing  that  if  the  cantharidal  inflammation 
was  the  cause  of  the  production  of  fibrinous  layers,  an  excess  of  inflamma- 
tion seems  not  to  have  the  same  effect;  at  least,  this  excess  gives  rise  to 
membranes  which  are  less  dry,  less  adherent,  though  more  numerous. 

When,  therefore,  the  sore  of  a  blister  is  covered  with  an  adherent 
false  membrane,  it  is  necessary  to  use  more  energetic  epispastic  ointments, 
plasters  and  paper. 

One  exception,  however,  must  be  noted  here.  It  sometimes  happens 
that  the  exposed  surface  becomes  all   at  once  very  painful,  and  covered 


264  THERAPEUTICS, 

with  soft,  grayish,  pultaceous  concretions  wliich  have  a  very  bad  smell. 
When  we  try  to  remove  them  the  blood  flows;  and  the  skin  which  sur- 
rounds them  has  an  erysipelatous  tint.  A  more  active  ointment  would 
only  aggravate  this  condition,  which  is  better  suited  by  emollient  cata- 
i:)lasms  at  first  and  powdered  calomel  afterwards,  or  a  cerate  made  of  1 
part  of  white  precipitate  to  38  of  Galen's  cerate;  this  dressing  promptly 
improves  the  condition  of  the  sore,  and  should  be  continued  until  the  in- 
flammation is  gone  and  laudable  suppuration  is  re-established. 

C.  TJie  blister  is  surroiuuled  by  a  dartrous  eruption. — It  very  often 
happens,  to  persons  subject  to  dartrous  affections,  that  the  skin  about  the 
blister  is  covered  with  vesicles,  at  first  separate,  but  afterwards  confluent, 
and  forming  a  genuine  eczema;  pustules  of  impetigo  may  even  appear, 
and  an  intolerable  itching  and  an  acute  pain  follow.  The  eczema,  at  first 
limited  to  the  arm  where  the  blister  was  applied,  often  extends  by  degrees, 
in  an  acute  form,  to  the  entire  surface  of  the  body.  Fever  is  then  kin- 
dled, and  general  symptoms  of  some  gravity  may  appear. 

But  in  non-dartrous  persons,  though  this  extension  of  inflammation  is 
quite  rare,  it  is,  nevertheless,  sometimes  seen,  especially  near  the  blister. 
The  remedies  which  we  have  found  most  useful,  while  the  eczema  remains 
confined  to  the  neighborhood,  are  at  first  dressing  with  a  linen  cloth 
soaked  in  glycerine;  and  soon  after,  when  the  local  phlegmasia  is  lessened, 
a  pomade  made  of  red  precipitate  1  gramme,  cerate  15  or  25  grammes; 
applications  of  a  liniment  of  equal  parts  of  lime-water  and  sweet  almond 
oil  or  linseed  oil,  morning  and  evening;  ointments  of  carbonate  or  acetate 
of  lead;  washes  with  Goulard's  vegeto-mineral  water,  etc.,  the  surface  of 
the  blister  being  less  energetically  stimulated  at  the  same  time. 

When  the  eczema  is  generalized  and  is  accompanied  by  febrile  reaction, 
a  bleeding  from  the  arm,  general  emollient  baths,  diet,  laxatives,  and 
afterwards  full  baths  containing  10  or  15  grammes  (  3  iijs. — iv.)  of  bichlo- 
ride of  mercury,  will  speedily  bring  relief. 

D.  The  blister  becomes  covered  with  vegetations. — When  the  blister 
has  been  long  and  severely  inflamed,  it  is  often  covered  with  vegetations 
like  old  sores.  In  this  case  superficial  cauterization  with  nitrate  of  silver, 
or  acid  nitrate  of  mercury,  the  application  of  powdered  burnt  alum,  sul- 
phate of  copper,  etc.,  usually  relieve  this  condition.  The  blister  should 
be  healed,  and,  if  necessar}'^,  another  one  made  elsewhere.  In  spite  of 
this  precaution,  the  cicatrix  will  remain  uneven,  sometimes  painful,  and 
cure  will  often  be  hard  to  obtain. 

E.  The  blister  causes  dysury. — This  usually  appears  on  the  day  the 
blister  is  applied.  It  is  caused  by  the  absorption  of  cantharidin  from  the 
denuded  surface.  The  only  remedy  is  to  make  the  patient  drink  freely; 
this  increases  the  quantity  of  urine,  and  no  irritation  of  the  urinary  pas- 
sages occurs.  In  very  irritable,  and  exceptionably  susceptible  patients, 
the  dressing  with  cantharidal  ointment,  etc.,  often  affects  the  bladder.  In 
this  case  we  must  immediately  substitute  mezereon  with  cantharides,  which 
of  itself  puts  an  end  to  all  the  trouble. 


IRRITANTS.  265 

If  we  cannot  make  this  substitution,  the  internal  use  of  camphor,  in 
the  dose  of  15 — 30  centigrammes  (gr.  2^ — i^)  is  advisable.  If  this  is  not 
borne,  dissolve  the  camphor  in  the  fatty  substances  which  are  used  for  dres- 
sing, and  you  will  very  probably  avoid  the  vesical  and  renal  difficulties. 

We  must  add  that  preparations  of  mezereon  produce  very  acute  pain, 
followed  by  bloody  irritations. 


Therapeutic  x^ction. 

In  spite  of  the  activity  of  this  remedy  (and  perhaps  because  of  it), 
some  therapeutists  have  ventured  to  prescribe  it  for  internal  use,  and 
have  been  followed  by  a  great  number  of  modern  practitioners  of  good 
reputation. 

The  father  of  medicine,  Hippocrates,  gave  the  j^owder  of  cantharides 
in  dropsy,  apoplexy  and  jaundice;  he  recommended  it  in  difficult  labors, 
to  solicit  the  expulsion  of  the  foetus  and  placenta.  He  believed  that  he 
had  proved  its  emmenagogue  virtues. 

impotence. — The  elective  affinity  of  cantharides  for  the  genito-urinary 
organs  was  recognized  in  the  first  age  of  medicine.  We  are  informed  by 
historians  that  they  formed  part  of  philters  or  love-potions.  Experience 
has  shown  that  the  internal  use  of  cantharides  places  these  organs  in  a 
condition  of  erethism  which  is  not  free  from  danger,  and  may  at  any  time 
cause  bloody  piss  and  inflammation  of  the  womb  or  penis,  and*  even 
sphacelus  of  the  latter.  We  advise  physicians,  if  ever  inclined  to  use 
cantharides  for  this  purpose,  to  be  extremely  careful,  and  to  restrain 
those  patients  who  wish  to  recall  a  long-regretted  but  unseasonable 
pleasui'e. 

Dysury. — In  spite  of  the  imposing  authority  of  Hippocrates,  the  inter- 
nal use  of  cantharides  for  diseases  other  than  impotence  had  almost 
ceased,  when  .1.  Groenevelt,  an  English  physician,  attempted  to  reinstate 
it;  becoming,  however,  the  object  of  very  active  persecution  from  his 
brethren.  He  gave  it  chiefly  in  dysury.  With  60  centigrammes  (gr.  9) 
of  powdered  cantharides  and  75  (12  gr.)  of  camphor,  he  made  two  or 
three  boluses,  which  were  to  be  taken  at  intervals  of  four  hours  (.1.  Groe- 
nevelt: ''Tutus  cantharidum  usus  intei*nus,''  Londini,  1(398).  Werlhoff 
("  Commercium  litterarium,"  year  1733)  recommends  this  in  dysuria;  he 
gave  cantharides  without  camphor,  5  centigrammes  of  powder  every  4 
hours.  In  dysury  of  old  men,  which  is  often  attributable  to  a  semi-pare- 
sis of  the  bladder,  this  treatment  is  plainly  rational  and  cannot  usually 
cause  any  decidedly  bad  symptoms;  but  if  due  to  chronic  inflammation 
of  the  neck  of  the  bladder,  such  as  may  be  due  to  a  calculus  or  the  fre- 
quent tearing  of  the  mucous  membrane  by  gravel,  or  if  due  to  a  serious 
swelling  of  the  prostate,  it  is  questionable  if  cantharides  will  render  the 
same  services;  these  and  other  considerations  have  thrown  discredit,  and 
still  do,  upon  the  internal  administration  of  cantharides. 


266  THERAPEUTICS. 

A  little  later  than  Groenevelt,  Th.  Bartolin  gave  a  vinous  infusion 
of  cautharides  in  blennorrhagia  ("Cantharidum  usus  internus,"  in  "  Hist, 
anatom.  cent,,"  V.,  hist.  82).  This  singular  remed}',  adopted  by  Werl- 
hoff,  was  again  used  and  highly  praised  by  Richard  Mead  ("  Monita  et 
jDriiecepta,"  Londini,  1754),  who  digested  8  grammes  of  powdered  cantha- 
rides  in  750  grammes  of  alcohol  (  5  ii. —  3  xxiv,),  of  which  tincture  he  gave 
from  30  to  59  drops  morning  and  evening;  and  in  our  times  we  have  seen 
Robertson,  of  Edinburgh,  treat  blennorrhagia  with  the  enormous  dose  of 
15  grammes  (  3  iv.)  of  tincture  of  cantharides  in  34  hours  ("Biblioth, 
medicale,"  t.  XX.,  p.  39), 

Our  view  of  the  action  of  copaiba  in  blennorrhagia  is  that  it  causes 
in  the  mucous  membrane  an  artificial  irritation  which  replaces  the  mor- 
bid irritation.  We  account  in  the  same  way  for  the  action  of  cantha- 
rides in  blennorrhagia  and  the  other  irritant  diseases  of  the  urinary  pas- 
sages; but  evidently  there  is  danger  here,  unless  the  physician  rightly 
proportions  the  artificial  local  inflammation  to  that  already  present.  We 
shall  give  rules  for  the  application  under  Substitutive  Treatment. 

Vesical  catarrh. — We  will  here  recall  what  we  said  above,  in  speak- 
ing of  the  physiological  action  of  the  remedy,  and  explain  how  we  are 
justified  in  comparing  the  internal  use  of  cantharides  up  to  a  certain  point 
with  irritant  injections  into  the  bladder,  or  urethra,  to  relieve  inflamma- 
tion of  their  mucous  membranes. 

The  writings  of  Morel-Lavallee,  and  Bouillaud,  and  the  inaugural 
thesis  of  M.  Dourif  (5  niai,  1840),  leave  little  to  be  desired  under  tiiis 
head. 

Bouillaud  finds  evident  traces  of  inflammation  of  the  kidneys  and  the 
ureter  after  applying  large  blisters.  He  has  once  found  small  false 
membranes  on  the  mucous  surface  of  the  pelves,  and  a  portion  of  false 
membrane  at  the  vesical  orifices  of  the  ureters,  showing  the  irritating- 
action  of  cantharides  upon  the  kidney  and  ureter.  He  also  found  the 
urine  albuminous  under  the  same  circumstances. 

Morel-Lavallee  has  proved  by  autopsies  (Andral  and  Vidal  of  Cassis 
state  the  same)  that  the  bladder  and  the  urethral  canal  are  inflamed  by 
the  same  cause.  He  has  sometimes  seen  the  vesical  mucous  membrane 
covered  with  a  real  fibrinous  false  membrane,  and  has  found  such  mem- 
branes in  the  chamber-pot. 

We  shall  not  speak  of  the  use  of  cantharides  in  epilepsy,  hydrophobia, 
hysteria,  etc. ;  the  heroic  and  dangerous  nature  of  a  remedy  attracts  some 
physicians  to  use  it  in  treating  acute  and  chronic  affections  which  are 
thought  incurable;  and,  as  it  is  hard  to  admit  a  failure,  the  value  of  a 
remedy  is  often  exaggerated,  until  the  physician  comes  to  deceive  him- 
self and  others. 

Eczema. — Cantharides  were  anciently  used  for  chronic  diseases  of  the 
skin,  as  in  the  case  of  that  Roman  knight  mentioned  by  Pliny,  who  was 
killed  by  drinking  a  potion  which  contained  cantharides,  given  to  cure  an 
obstinate  eruption.     We   must  come  down   nearly  to  our  own  time   to 


IRRITANTS.  267 

find  it  used  by  physicians.  Lorry  ("  Tractatus  de  morb.  cutan.,"  Paris, 
1777,  p.  388)  recommends  tincture  of  cantharides  in  elephantiasis  graeco- 
rum,  and  states  positively  that  in  his  time  it  was  much  used  by  English 
physicians  for  skin  diseases. 

Biett,  who  is  reported  by  Cazenave  ("Diet,  de  med.,"  2e  edit.,  t.  VI., 
p.  349)  to  have  used  alcoholic  tincture  of  cantharides  at  the  hospital  of 
Saint  Louis  for  more  than  twenty  years,  in  a  great  number  of  diseases, 
obtained  very  good  results,  chiefly  in  certain  chronic  eczemas  and  der- 
matoses of  the  squamous  form.  The  tincture,  in  the  dose  of  3  drops  at 
first,  and  gradually  increased  to  20  or  more,  is  very  successful  in  psoria- 
sis, and  still  more  so  in  lepra  vulgaris.  If  given  with  prudence  and 
closely  watched,  it  causes  no  accidents;  under  its  influence  the  skin  re- 
sumes vigor,  the  papular  elevations  disappear,  and  in  a  month  or  six 
weeks,  and  often  earlier,  we  may  obtain  the  complete  cure  of  a  disease 
which  had  lasted  for  months.  It  is  worthy  of  remark  that  the  remedy  acts 
more  speedily  and  effectually  in  women,  arid  in  young,  sanguine  and  active 
persons,  than  in  the  weak.  We  even  admit  that  cantharides  may  have  a 
very  special  action  upon  certain  forms  of  this  disease. 

The  ointment  of  Dupuytren  is  intended  for  baldness.  It  is  plain  that 
in  some  cases  the  loss  of  hair  is  caused  by  an  herpetic  affection  of  the 
scalp,  and  for  this  reason  a  substitutive  irritation  with  an  ointment  may 
arrest  this  cause  by  curing  the  affection  of  the  skin.  But  when  the  bald- 
ness is  hereditary,  or  due  to  age,  or  is  accompanied  (as  usually  is  the 
case),  by  atrophy  of  the  bulbs,  it  is  too  plain  that  no  ointment  can  re- 
store to  the  skin  of  the  scalp  its  normal  anatomical  structure. 

The  physicians  of  India  vise  not  only  cantharides,  but  several  sorts  of 
mylabris,  as  the  m.  cichoris,  puncta,  pustulata,  and  indica.  The  natives 
of  the  marshes  of  Pondicherry  use  the  root  of  plumbago  zeylanica  in 
powder,  which  is  said  to  have  the  advantage  of  not  acting  on  the  urinary 
organs,  while  ammania  vesicatoria  is  only  a  vesicant  of  inferior  power  to 
the  preceding  ( Gaz.  hebd.,  aout,  1861). 


Injurious  Effects  of  Blisters. 

The  revulsive  action  of  blisters  is  one  of  the  most  precious  acquisi- 
tions of  therapeutics,  but  it  must  not  be  forgotten  that  it  is  attended 
with  dangers.  The  irritation  of  the  skin  may  go  beyond  vesication;  we 
have  spoken  of  diphtheria  of  the  sore;  in  persons  of  enfeebled  constitu- 
tion, ulceration,  anthrax,  furuncles,  even  gangrene  of  the  exposed  sur- 
face may  occur;  or  it  may  become  the  starting-point  of  erysipelas.  We 
have  mentioned  the  irritation  of  the  genito-urinal  passages;  they  may 
become  extremely  intense;  and  the  albuminuria,  which  is  usually  transient, 
maybe  prolonged  and  degenerate  into  Bright's  disease  (Cornil:  "  Des 
differentes  especes  de  nephrites,"  1869). 

The  indications  for  blisters  are  given  under  "Irritant  Treatment." 


268  THERAPEUTICS. 


Mezereox. 

The  different  species  of  this  plant  Avere  once  used  as  stimulants  and 
diaphoretics,  especially  in  diseases  of  the  bony  system,  in  osteocopic 
pains,  exostoses,  scrofula,  dartrous  affections,  and  chronic  rheumatism. 
A  great  many  authors,  including  Russel,  Home,  Swediaur,  Wright,  recom- 
mend the  bark  as  of  great  value,  especially  in  constitutional  syphilis.  It 
is  no  doubt  upon  the  authority  of  these  that  Cazenave  desired  to  re-in- 
troduce it  in  the  treatment  of  syphilis. 

It  requires  to  l)e  used  with  care,  as  it  is  capable  of  causing  rather  se- 
vere effects.  We  have  seen  a  patient  affected  with  local  paralysis,  which 
was  supposed  to  be  due  to  an  intracranial  syphilitic  exostosis,  who,  after 
taking  a  decoction  of  mezereon,  suffered  from  severe  trouble  of  the  blad- 
der, on  two  distinct  occasions;  so  that  the  man's  regular  attendant,  who 
at  first  had  refused  to  believe  that  the  remedy  acted  thus,  was  obliged  to 
submit  to  the  evidence  and  abandon  the  remedy.  Is  this  fact  excep- 
tional, or  does  mezereon  exert  in  a  very  slight  degree  an  irritant  action 
upon  the  urinary  passages  analogous  to  that  of  cantharides  ?  This  ques- 
tion we  cannot  decide. 

The  decoction,  given  internally,  is  made  with  from  1  to  8  grammes 
(gr.  15 — 3  ii.)  to  the  quart  of  water. 

The  bark  is  used  as  an  epispastic;  but  it  acts  slowly,  and  this  way  of 
applvino-  blisters  can  only  be  used  where  the  skin  is  extremely  fine,  as  be- 
hind the  ears;  or  in  the  case  of  patients  who  are  irritated  by  cantharides. 

To  produce  vesication  or  rubefaction  with  the  bark,  we  choose  a  flexi- 
ble and  single  piece,  which  is  to  be  macerated  in  water,  or  better,  in 
vinegar  ;  this  is  placed  on  the  skin  so  as  to  be  in  very  close  contact.  In 
twenty-four  or  thirty-six  hours,  very  small  vesicles  are  seen  rising,  and 
by  continuing  the  application  and  frequently  renewing  it  we  form  a  su- 
perficial ulceration  which  may  be  long  maintained  by  the  same  means. 

Leclerc  of  Tours  has  prepared  aqueous,  alcoholic  and  ethereal  extracts 
of  mezereon  bark.  An  epithem  made  with  each  was  applied  to  the  fore- 
arms of  three  patients.  The  ethereal  extract  alone  produced  an  energetic 
action.  A  large  number  <}f  small  vesicles  full  of  a  turbid  serum  were 
formed  on  the  spot  covered  by  this  epithem.  A  simple  rubefaction  was 
obtained  by  the  alcoholic  extract,  while  the  watery  extract  produced  no 
effect  (Leclerc  :  "  Essai  sur  les  epispastiques,"  Journal  des  connalssances 
mecUco-chirurgicales,  t.  III.,  p.  92). 

It  hence  appears  that  if  we  desire  to  make  an  ointment  of  mezereon, 
for  the  purpose  of  exciting  suppuration  in  blisters,  we  should  always  use 
the  ethereal  extract,  which  should  also  be  preferred  to  the  bark,  when  we 
wish  to  excite  a  little  inflammation  on  a  portion  of  delicate  skin. 

Mezereon  is  the  basis  of  most  epispastic  papers  for  keeping  open 
blisters. 


IRRITANTS.  26y 


Nettle. 


The  urtica  ureris  is  ordinarily  used  in  external  medicine. 
Jfrtication. — This  term  signifies  the  irritant  effect  produced  upon  the 
skin  by  contact  with  nettles.  To  produce  it,  make  a  little  bunch  of  the 
longest  stems  of  the  u.  urens,  and  strike  several  times  lightly  on  the  part 
of  the  skin  you  wish  to  irritate.  The  skin  is  almost  immediately  covered 
with  large,  flat,  white,  irregular  papules,  which  cause  an  insupportable 
burning  pain.  This  genuine  "  urticaria  "  disappears  with  the  same  rapid- 
ity, and  the  operation  must  be  repeated  in  order  to  recall  it;  but  the 
skin  does  not  respond  so  readily  to  subsequent  appeals,  and  the  third  or 
fourth  application  may  have  no  marked  effect.  For"  this  reason,  country- 
women gather  nettles  with  perfect  impunity. 

Urtication  has  been  recommended  for  the  purpose  of  recalling  exan- 
themata, and,  in  general,  all  external  fluxions  that  develop  slowly  or  tend 
to  disappear,  and  likewise  in  all  other  cases  where  it  is  important  to  set  up 
an  energetic  fluxion  to  the  skin. 

Thus  Celsus  and  Aretseus  advise  urtication  in  coma  and  paralysis 
("  De  re  medica,"  lib.  3,  cap.  27. — "  Curat,  acut.,"  lib.  1,  cap.  3).  Others 
have  used  it  upon  the  thighs  to  recall  the  menses  {Bull,  de  Ferussac,  t.  IX., 
p.  77).     It  has  also  been  recommended  in  anaphrodisia. 

In  the  epidemics  of  cholera  which  have  passed  through  our  country, 
a  certain  number  of  physicians,  especially  in  the  country,  have  used  urti- 
cation in  the  cold  stage.  When  the  skin  retains  sensibility,  and  the  algid- 
ity is  not  complete,  some  good  effects  have  been  produced;  but  it  has 
been  praised  ridiculously,  and,  on  the  whole,  it  is  neither  better  nor  worse 
than  most  other  irritants  of  the  skin. 


R  AXUNCUL  ACE^. 

Many  members  of  this  family  of  plants  have  a  very  powerful  action  on 
the  skin.  The  species  which  compose  the  genera  clematis,  anemone,  ra- 
nunculus (Linnneus),  are  the  most  active.  We  particularly  mention  ra- 
nunculus sceleratus.  It  has  been  recommended  as  a  cataplasm,  to  pro- 
duce resolution  of  swollen  glands  and  cold  abscesses. 

The  clematis  vitalba  (beggars'  plant)  owes  its  popular  name  to  the  use 
which  beggars  make  of  it  to  produce  upon  their  limbs  appearances  which 
excite  the  pity  of  the  public.  This  action,  says  Leclerc  ("Essai  sur  les 
6pispastiques,"  Joxirnal  cles  co7niaisscmces  medlco-chirurgicales,  t.  III.,  p. 
91),  is  analogous  to  that  of  mustard;  it  is  profound,  yet  it  quite  rarely  raises 
the  skin.  The  inflammation  it  causes  extends  to  the  whole  depth  of  the 
skin,  and  beyond. 

These  vegetables  owe  their  irritant  properties  to  an  acrid,  volatile  oil, 
difficult  to  obtain  by  distillation;  this  principle  irritates  the  pituitary  mem- 


-270  THERAPEUTICS. 

brane,  excites  lachryination,  and  possesses  a  great  analogy  to  that  of  some 
liliaceffi  and  cruciferte,  especially  horseradish.  It  is  dissipated  by  drying, 
so  that  the  dried  ranunculacefe  have,  so  to  speak,  no  irritant  property,  and 
cattle  may  eat  them  without  injury. 

These  plants  may  be  used  when  mustard  cannot  be  got;  they  are 
beaten  to  a  pulp,  and  act  with  sufficient  force  when  placed  between  two 
cloths. 

Clematis  is  often  used  in  Holland  as  a  diuretic  in  dropsy.  A  physician 
of  Liege,  M.  Sauveur,  has  used  an  infusion  of  clematis-seed  in  two  cases 
of  albuminuria  symptomatic  of  Bright's  disease;  he  states  that  an  abun- 
dant diuresis  was  established,  the  quantity  of  albumen  in  the  urine  less- 
ened from  day  to  day,  and  the  dropsy  disappeared  ( Gaz.  med.-chir.  de 
Liege,  nov.,  1864). 

EUPHORBIACE^. 

A  rather  intense  vesicular  inflammation  of  the  skin  is  produced  by  some 
of  these  plants;  among  others,  by  thecroton  tiglium  (the  oil)  and  euphor- 
bia lathyris  (the  milky  juice).  These  two  oils,  when  spread  on  the  skin, 
produce  a  genuine  dermatitis  with  pustules. 

The  amount  to  be  applied  varies  trom  10  to  40  drops.  One  applica- 
tion will  produce,  after  a  few  hours,  all  the  signs  of  inflammation,  painful 
sensibility,  redness,  swelling,  heat;  and  in  24  hours  vesicles  are  developed. 
The  latter  are  usually  discrete,  separate,  but  in  many  places  run  together 
and  may  form  buH*. 

The  contents  of  the  vesicles  are  at  first  transparent,  and  may  remain 
so  throughout,  but  usually  grow  turbid  and  purulent  on  the  second  day. 
The  pustules  are  at  first  tense  and  shining,  but  soon  sink  and  become  wrin- 
kled. Sometimes  the  pustule  breaks  and  displays  a  superficial  ulceration, 
limited  by  a  strip  of  epidermis,  and  soon  covered  with  a  yellowish  crust. 
In  a  week  the  eruption  is  cured,  and  nothing  remains  but  a  spot  which 
has  the  color  of  ephelis. 

This  eruption  is  usually  quite  painful  during  the  whole  period  of  its 
development,  and  sometimes  later,  if  ulcerated. 

Certain  secondary  eruptions  should  be  mentioned.  A  patient,  suffer- 
ing from  the  itching  which  the  eruption  produces,  will  often  put  his  hands 
upon  it  to  scratch,  and  will  afterwards  put  them  on  his  face  or  scrotum, 
and  cause  in  those  places  a  dermatitis  which,  though  it  does  not  usually 
cause  pustules,  is  quite  painful,  particularly  on  the  scrotum.  The  same 
thing  happens  to  the  person  who  makes  the  application,  if  he  does  not 
sufficiently  cleanse  his  hands  afterwards. 

The  volatile  portion  of  the  oil  may  spread  the  dermatitis  to  neighbor- 
ing parts;  in  particular  to  the  face,  when  it  is  rubbed  on  the  neck. 

Laryngitis. — lironchitis. — Croton  oil  is  used  as  a  revulsive,  most  com- 
monly to  combat  acute  catarrhal  affections  of  the  larynx  and  bronchi.     It 


IRRITAKTS.  271 

is  used  almost  constantly  to  relieve  a  laryngitis  which  has  little  of  tiie  in- 
flammatory element,  but  is  accompanied  by  aphonia  due  to  paresis  of  the 
vocal  cords. 

It  is  also  used  in  chronic  recurrent  bronchitis  and  in  phtliisis,  to  re- 
lieve acute  attacks  of  tubercle  or  caseous  pneumonia.  The  attempt  to 
relieve  meningitis  or  enteritis  has  proved  unsuccessful,  and  has  been  aban- 
doned. 

Dropsy  In  dUease  of  the  heart. — Anasarca. — The  description  given 
above  of  the  action  of  croton  oil  was  interuded  to  apply  to  the  healthy 
skin.  In  anasarca,  produced  by  disease  of  the  heart,  two  different  con- 
ditions may  exist  in  the  skin  of  the  lower  limbs.  In  some  cases,  wliile 
the  anasarca  is  considerable  and  the  skin  distended,  the  skin  is  thick  like 
that  of  pachyderms,  exempt  from  the  anasarca,  as  it  were.  It  is  cede- 
matous,  and  keeps  the  print  of  the  finger,  but  is  as  hard  as  leather.  If 
these  patients  are  rubbed  liberally  with  croton  oil,  the  eruption  produced 
will  be  insignificant.  Red  acuminated  points,  with  a  hair  in  the  middle, 
will  be  seen  here  and  there,  forming  an  artificial  acne;  there  is  a  little 
dermatitis,  with  some  pain,  but  no  abundant  secretion. 

The  case  is  quite  otherwise  when  the  skin  is  smooth  and  transparent, 
and  so  infiltrated  that  it  seems  ready  to  break  out  at  any  moment.  If  in 
such  a  case  we  make  an  application  of  croton  oil  as  before,  the  eruption 
will  be  extremely  abundant,  and  a  considerable  number  of  vesicles  will 
form,  which  will  soon  become  confluent  and  will  break  almost  immediate- 
ly. The  patient  is  inundated  with  a  very  large  quantity  of  liquid,  pro- 
ceeding not  from  the  secretions  of  the  vesicles  alone,  but  from  all  the 
openings  of  the  ulcerations  produced  by  the  irritant.  It  is  a  genuine 
flux,  and  changes  the  patient's  condition  so  rapidly  that  if  the  ph^^sician 
has  never  seen  it  before,  it  causes  much  uneasiness. 

The  first  effect  of  this  active  treatment  is  to  produce  an  enormous 
spoliation,  which  seems  to  exhaust  the  patient.  The  appearance  of  the 
limbs  is  not  reassuring;  they  form  a  vast  sore  with  a  grayish  base,  resem- 
bling an  immense  sphacelus.  But  on  the  second  day  there  is  a  change. 
The  depletion  of  the  circulatory  system  allows  the  patient  to  breathe  more 
deeply,  the  heart  and  blood-vessels  regain  energy,  hajmatosis  is  re-estab- 
lished, the  skin  becomes  more  clear,  and  the  color  of  the  face  better. 
The  alai'ming  sore  retains  the  appearance  of  an  eschar  for  some  days, 
but  recovers  much  sooner  than  one  would  suppose. 

We  have  many  times  employed  this  practice  where  digitalis,  diuretics, 
and  purgatives  had  ceased  to  act,  and  have  been  enabled  to  restore  per- 
sons to  life  Avhen  the  progressive  asystole  threatened  a  speedy  death. 

We  only  recommend  that  the  oil  shall  be  applied  chiefly  to  the  legs 
and  knees,  avoiding  the  upper  parts  of  the  thighs;  for  when  the  appli- 
cation has  been  made  in  the  latter  place,  the  scrotum  ulcerates,  leaving 
very  troublesome  sores,  often  very  hard  to  cure,  which  make  all  the  pa- 
tient's movements  painful. 

Chronic  rheumatism. — Ten  vears  ao-o  a  Q-reat  noise  was  made  about 


272  THERAPEUTICS. 

a  secret  i)rocess  which  a  charalatan  from  Germany  brought  to  Paris, 
called  Baunscheidtism.  It  consisted  simply  of  making  punctures  in  the 
skin  by  an  instrument  which  thrust  out  a  row  of  needles;  the  punctures 
were  covered  with  an  irritant  composed  of  two  parts  of  oil  of  sweet  al- 
monds and  one  of  croton  oil.  Thus,  by  inoculation,  a  sort  of  eruption 
was  obtained  resembling  acne,  and  recalling  in  its  intensity  the  eruption 
produced  by  thapsia. 

This  process  is  now  performed  with  a  cylinder  covered  with  needle- 
points (a  spur  might  answer),  which  is  held  by  an  axis,  and  is  rolled  over 
the  surface  of  tlie  skin;  the  mixture  just  named  is  afterwards  applied. 
The  treatment  has  some  efficac}^  but  may  advantageously  be  replaced  by 
friction  with  essence  of  turpentine. 


Pitch. — Tuepentine. 

Of  Burgundy  pitch  and  turpentine  as  local  excitants  we  will  speak 
in  a  subsequent  chapter  devoted  to  that  subject.  We  give  here  the  Poor- 
man's  plaster : 

^'  Tar  Paper. 

Poor-man's  Plaster  (Charta  picata). 

I^ .    Kosin 300  grammes. 

Purified  'J  ar 200 

Yellow  Wax 100 

Melt  togetiior  and  spread  thin  on  paper,  like  a  plaster. 

Resin  of  Tiiapsia  Garganica. 

This  resin,  obtained  by  the  action  of  boiling  alcohol  on  the  bark  of  the 
root  of  the  plant  (an  umbellifera,  very  common  in  Algiers),  was  pro^ 
posed  by  MM.  Rel^ouileau  and  A.  Bertherand  in  1857.  The  former  made 
a  vesicating  plaster  of  the  resin,  which  was  of  a  tine  yellow,  shining  and 
very  adhesive;  it  produces  on  the  skin  a  rubefaction  accompanied  by  a 
very  intense  miliary  eruption  analogous  to  that  caused  by  the  application 
of  croton  oil. 

Plaster  of  Eeshi  of  Thapsia. 

^.     Yellow  wax 420  grammes=  3  xiii.  3  i. 

Rosin 150  "      "        =3  iv.  3  vss. 

Burgundy  pitch 150         "       =3  iv.  3  vss. 

Boiled  turpentine 150  "        =  §  iv.  3  vss. 

Turpentine  from  the  larch 50  "        =  S  i.  3  iv.  gr.  1. 

Glycerine 50  "        =  3  i.  3  iv.  gr.  1. 

White  honey 50  "        =  3  i.  3  iv.  gr.  1. 

Resin  of  thapsia 75  "        =  3  ii.  3  iii,  gr.  xv. 

Melt  together  the  first  live,  and   strain   through   linen.     Keep  them 


IRRITANTS.  273 

liquid  over  a  very  gentle  fire,  and  add  the  glycerine,  the  honey,  and  the 
thapsia  resin  (it  should  be  of  the  consistency  of  honey).  When  the  mix- 
ture is  very  homogeneous,  spread  on  strips  of  linen  as  for  ordinary  plas- 
ters. 

The  eruption  produced  by  thapsia  greatly  resembles  that  produced  by 
croton  oil  or  euphorbia  lathyris,  but  differs  in  the  following  points: 

1.  In  its  uniformity  and  regularity,  all  the  pustules  being  alike. 

2.  In  the  large  number  of  pustules. 

3.  In  the  rapidity  with  which  pus  appears  in  the  vesicles. 

18 


IRRITANTS   IN   GENERAL. 


Irritants  are  agents  which  produce  an  irritation  at  the  points  to  which 
they  are  applied. 

The  science  of  irritant  treatment  includes  the  physiological  effects  of 
these  agents,  and  the  relation  between  these  effects  and  the  therapeutic 
indications  they  are  called  on  to  fulfil. 

We  shall  divide  the  subject  into  four  sections:  substitutive,  transpo- 
sitive,  spoliative,  and  excitative,  irritant  treatment. 


Substitutive  Treatment. 

The  homoeopathic  doctrine,  considered  in  its  general  fundamental  idea, 
certainly  does  not  deserve  the  ridicule  which  the  therapeutic  applications 
made  by  the  homoeopaths  have  occasioned. 

When  Hahnemann  uttered  the  principle  "  similia  similibus  curantur," 
he  proved  his  position  by  facts  taken  from  the  practice  of  the  most  en- 
lightened physicians.  It  is  fully  proved  that  the  local  phlegmasiae  are 
often  cured  by  the  direct  application  of  irritants,  which  cause  an  analo- 
gous inflammation  of  a  medicinal  character,  which  takes  the  place  of  the 
primitive  irritation. 

That  which  was  true  in  regard  to  local  diseases  and  topical  agents  was 
certainly  much  less  so  in  general  diseases  and  remedies;  but  Hahnemann, 
dazzled  by  the  truth  of  an  idea  which  he  had  guessed  and  formulated, 
soon  exaggerated,  like  all  innovators,  the  importance  of  his  discovery. 

His  disciples,  as  always  happens,  soon  outran  their  master,  and  car- 
ried him  away  with  their  exaggerated  ideas ;  German  mysticism  soon 
added  its  contributions,  and  the  system  gained  many  partisans,  for  there 
is  no  idea  so  absurd  that  it  does  not  find  physicians  to  maintain  it  and 
patients  to  throw  themselves  in  the  way  of  experiments.  Homoeopathy 
has  had  its  run  in  Paris,  as  everywhere;  there  is  hardly  a  physician  but 
has  lost  some  patients  by  it;  but  now  that  the  infatuation  is  past,  and  it 
requires  no  courage  to  enter  on  a  combat  with  an  enemy  disarmed  by  ridi- 
cule and  failure,  let  us  try  to  discover  what  is  of  practical  value,  not  in 


IRRITANTS    IlSr    GENERAL.  275 

the  dreams  of  old  homoeopathy,  but  in  the  first  idea  that  broke  from  the 
brain  of  Hahnemann. 

When  a  morbific  cause  is  applied  to  a  man's  body,  it  produces  effects 
which  are  necessarily  related  to  the  nature  of  the  cause  and  to  the 
state  of  the  economy  which  receives  the  impression. 

Nature  of  the  cause. — According  to  Brown  and  Broussais,  there  exists 
but  one  cause  of  disease,  the  application  of  excitants  to  the  body.  Every 
cause  acts  simply  by  the  greater  or  less  excitation  which  it  produces — ex- 
citants as  the  cause,  excitation  as  the  effect;  this  is  about  the  sum  of  the 
pathological  doctrine  of  these  great  innovators.  The  difference  in  the  in- 
tensity of  the  cause,  and  in  the  mode  of  reaction  of  the  economy,  are  the 
source  of  the  innumerable  varieties  of  morbid  forms.  The  different  inter- 
pretation which  Brown  and  Broussais  drew  from  the  play  of  reaction 
caused  the  prodigious  divergence  in  their  therapeutical  conclusions.  And 
yet  the  fundamental  idea  of  their  doctrine  is  identical;  Broussais  recog- 
nized it  when  he  took  the  synthetic  proposition  of  Brown's  doctrine  for 
the  text  of  his  own  teaching. 

As  we  have  said,  Brown  and  Broussais  admitted  as  an  axiom  an  erro- 
neous proposition  which  nothing  as  yet  proves;  and  since  their  whole 
doctrine  rested  on  this  fragile  foundation,  they  succeeded,  while  reason- 
ing with  much  vigor  and  logic,  in  reaching  the  most  incorrect  conclu- 
sions. 

That  life  is  kept  up  only  by  stimulants,  is  an  apparently  self-evident 
truth;  but  if  we  reflect  a  moment  we  shall  see  that  it  is  not  provable. 

It  certainly  cannot  be  denied  that  life  is  kept  up  only  by  modifiers; 
the  truth  of  this  proposition  is  trivial;  but  it  has  exactly  the  triviality 
which  belongs  to  axioms,  and  therein  lies  its  value.  The  words  modifier 
and  modification  express  facts  which  are  not  opinions;  the  words  stimu- 
lant and  excitation  substitute  an  opinion  for  facts,  and  the  reasoning  is 
bad. 

It  is  a  fatal  error  in  philosophy  to  attach  to  words  only  a  slight  im- 
portance; in  leading  propositions  words  are  of  the  highest  moment,  and 
their  sense  ought  to  be  so  clear  that  their  use  in  discourse  should  never 
check  the  comprehension  of  the  reader. 

We  shall  presently  see  the  importance  which  belongs  to  the  ideas  of 
modification  and  modifiers,  and  how  much  better  they  represent  facts 
than  does  excitation,  the  principle  of  Brown  and  Broussais. 

In  fact,  for  these  two  pathologists,  everything  lies  in  the  quantity 
of  the  stimulus,  provided  that  the  organic  state  is  alike  in  all  men. 

The  gravity  of  a  pneumonia,  cjBteris  paribus,  depends  on  the  quantity 
of  stimulus  applied  to  the  pulmonary  parenchyma.  With  this  a  j^ropor- 
tional  extent  of  local  lesion  and  of  reaction  exactly  corresponds.  And  so 
in  the  pleura,  pericardium,  peritoneum,  liver,  brain,  uterus,  etc. 

These  facts  are  incontestable;  it  is  their  evident  truth  that  leads  astray 
the  illustrious  men  with  whom  we  differ.  When  it  is  shown  that  exter- 
nal and  physical   agencies,  which  are  plainly  the  same  for   all,  bring  to 


276  THERAPEUTICS. 

pass  different  results,  they  invoke  the  difference  in  organisms;  and  in 
this  they  are  correct. 

Herein  are  included  a  large  part  of  the  diseases  which  in  strictness 
are  embraced  within  their  system. 

But  they  were  soon  shaken  by  the  pathologists,  who  devoted  them- 
selves to  the  study  of  special  diseases;  Bretonneau,  in  particular,  in  call- 
ino-  attention  to  special  lesions  of  the  mucous  membrane — e.  g.,  diphthe- 
ria and  dothinenteritis — inflicted  upon  the  doctrines  of  Edinburgh  and 
the  Val-de-Grace  a  blow  the  gravity  of  which  Broussais  vainly  attempted 
to  deny.  Bretonneau  agrees  with  us  in  thinking  that  differences  in  dis- 
eases are  due  much  more  to  difference  in  their  causes  than  to  variety  of 
organization. 

In  our  view,  it  is  less  the  quantity  of  action  of  the  morbific  cause,  than 
the  quality  of  the  modifier,  that  determines  the  nature  of  a  disease;  as  it 
is  not  the  quantity  but  the  quality  of  a  seed  that  determines  the  nature 
of  a  crop. 

Quantity  gives  for  a  result  only  more  or  less ;   quality  gives  species. 

There  is  to-day  no  pathologist,  however  obstinately  he  may  cling  to  a 
dichotomic  doctrine,  that  does  not  admit  certain  local  or  general  diseases, 
in  which  are  observed  certain  forms  so  constant  and  invariable  that  one  is 
forced  to  admit  the  importance  of  the  quality  of  the  modifier.  In  their 
view  these  diseases  are  the  minority;  in  ours,  they  are  the  more  com- 
mon. 

And  first,  all  the  contagious  diseases,  without  exception,  are  special 
diseases.  Of  these  we  may  justly  say  that  they  are  sown  from  seed,  and 
necessarily  retain  some  of  the  quality  of  a  generative  agent.  And  con- 
tagious diseases  are  much  more  frequent  than  is  commonly  supposed. 

If  we  exclude  the  idea  of  contagion,  and  class  diseases  by  their  local 
and  general  symptoms  only,  we  shall  at  once  find  the  class  of  special  dis- 
eases to  be  so  broad  as  to  fill  the  greater  part  of  nosology. 

Taking,  by  way  of  example,  those  modifiers  whose  effects  are  the  easiest 
to  follow,  we  see  that  the  chemical  agents,  when  applied  to  the  body, 
produce  each  its  special  action.  Thus,  the  chlorides  of  gold,  arsenic,  zinc 
and  antimony;  fire;  potassa,  soda,  lime;  nitric,  sulphuric,  muriatic  and 
fluoric  acids;  the  salts  of  silver,  copper,  mercury,  etc.,  act  upon  the  skin  so 
differently,  that  with  a  little  practice  one  may  recognize  the  agent  by  its 
physical  or  chemical  action  upon  the  tissues,  and  by  the  local  reaction 
which  succeeds  its  application. 

Here,  evidently,  we  cannot  argue  from  the  quantity  of  action,  for 
experience  shows  that  we  can  never  do  with  nitrate  of  silver  what  we  can 
with  butter  of  antimony,  whatever  be  the  doses.  It  matters  little  that 
this  is  due  to  the  different  chemical  qualities  and  modes  of  combining 
with  the  tissues,  provided  there  be  a  difference,  and  a  constant  difference. 

If  now  we  examine  the  poisons,  we  see  each  acting  in  its  own  way, 
so  that  the  slightest  examination  almost  always  enables  us  to  distinguish 
the  nature  of  the  poison.     The  least  skilled  specialist  can  distinguish  the 


IRRITANTS    IN    GENERAL.  277 

poisonous  effects  of  opium  from  those  of  stramonium,  veratria  and  strych- 
nia ;  those  of  lead  form  those  of  mercury,  copper  and  arsenic  :  he 
readily  notes  the  difference  in  the  effects  of  the  poison  of  the  rattlesnake, 
the  viper,  the  scorpion,  the  bee,  the  tarantula,  the  mad  dog,  the  animal 
affected  with  malignant  pustule.  Each  cause  has  a  special  effect,  char- 
acterized by  a  particular  form,  reproduced  in  each  case  like  the  specific 
character  of  a  series  of  individuals  in  a  species. 

What  can  we  add  of  the  poison  of  small-pox,  vaccinia,  scarlatina, 
measles,  syphilis,  that  has  not  been  told  at  all  times  and  places  ? 

That  which  we  see  in  men,  we  see  in  animals — nay,  in  plants,  whose 
organization  is  so  inferior;  in  their  pathological  disorders  the  plants  bear 
a  powerful  testimony  to  the  influence  which  the  nature  of  a  cause  has  on 
the  form  of  a  disease.  The  insects  which  sting  the  leaves  or  twigs  pro- 
duce at  the  point  of  contact  morbid  excrescences,  which  unmistakably 
recall  the  agent;  the  form  of  gall  that  follows  the  prick  of  a  given  insect 
is  so  constant  that  the  skilled  naturalist  can  always  infer  the  nature  of 
the  contained  larva  from  the  form,  color  and  volume  of  the  swelling. 

These  are  not  idle  questions,  but  will  establish  the  fact  of  specificity 
of  duration,  a  great  point  in  substitutive  treatment. 

In  all  these  instances  it  would  be  flagrantly  absurd  to  attribute  the 
effects  solely  to  the  quantity,  and  not  to  the  quality  of  the  cause.  What- 
ever the  quantity  of  variolous  virus  employed,  it  is  as  impossible  to  pro- 
voke with  it  the  symptoms  of  hydrophobia,  as  to  make  with  escharotics 
an  eschar  that  shall  behave  like  malignant  pustule. 

If  it  is  absurd  to  deny  to  the  quality  of  the  cause  an  immense  share  in 
the  form  of  the  effect,  it  is  almost  as  absurd  to  exclude  quantity  as  a 
causal  element.  The  matter  of  more  or  less  is  a  very  important  portion 
of  a  cause,  as  regards  the  intensity  of  effect — but  not  as  regards  the  inti- 
mate nature  of  the  effect. 

Hitherto  we  have  descended  from  cause  to  effect.  The  cause,  being 
well  known,  well  appreciated,  in  the  time  of  its  application  to  the  body, 
if  not  in  its  intimate  nature,  is  easily  followed  in  the  play  of  reaction 
which  it  causes  in  the  system,  and  the  special  form  of  the  secondary  phe- 
nomena is  easily  followed.  If  all  causes  were  as  easy  to  grasp,  there 
would  be  no  difficulty,  and  specialty  would  be  easily  proved  in  almost  all 
diseases;  but  in  a  great  many  cases  the  cause  is  unknown,  the  effect 
alone  is  before  us,  and  we  have  to  ascend  from  a  known  effect  to  an  un- 
known cause. 

The  specialty  of  a  disease  is  as  well  proved  by  the  invariability  of  its 
forms,  independently  of  the  causes  which  produce  it,  as  if  the  effect  and 
the  cause  were  both  known. 

The  causes  of  most  of  the  functional  troubles  of  the  bowels  are  wholly 
unknown  to  us;  but  the  lesions  connected  with  those  functional  troubles 
are  so  invariable  in  form  that  we  accept  their  specific  nature  at  once. 
Between  Asiatic  cholera,  dysentery,  and  dothinenteritis,  the  differences 
are  so  marked  and  the  symptoms  accompanying  them  are  so  positive,  that 


278  THERAPEUTICS. 

the  least  skilled  can  distinguish  them  from  one  another;  and  the  possi- 
bility of  such  distinction  implies  the  idea  of  specialty,  for  no  distinction 
is  possible  unless  there  exist  specific  characters,  and  the  establishing'  of 
these  characters  at  once  proves  specificity. 

In  the  three  diseases  of  which  we  have  just  spoken,  the  nature  of  the 
affection  is  certainly  not  inferred  from  the  phenomenal  quantity,  that  is, 
the  intensity  of  each  symptom,  but  by  the  qualit}'^,  that  is,  the  special 
form  of  certain  phenomena,  independently  of  their  intensity. 

We  can  never  turn  a  dotiiinenteritis  into  x\siatic  cholera,  nor  a  dvs- 
entery  into  cholera  morbus,  whatever  be  the  severity  of  the  diseases. 
Each  will  preserve  its  distinct  features  and  its  specific  characteristics.  It 
is  philosophical  to  infer  constancy  of  causes  from  constancy  of  effects. 
Nor  is  it  more  logical  to  presume  an  identical  cause  for  cholera  and  yellow 
fever,  than  it  is  to  ascribe  small-pox  and  scarlet  fever  to  the  action  of  the 
same  virus. 

The  followers  of  Brown  and  Broussais,  after  a  long  struggle  with  the 
arguments  which  were  ruining  their  dichotomic  doctrine,  were  at  last 
forced  to  recognize  special  diseases;  and  as  if  their  system  were  not  de- 
stroyed b\'  this  admission,  the}'  made  another  attempt  to  reconcile  the 
doctrine  of  specialty  with  their  own  narrow  theories. 

What  does  it  matter  to  Brown  whether  small-pox  is  a  special  disease 
or  not?  It  is  nothing  to  him;  he  attends  solely  to  the  fact  that  it  is 
sthenic  or  asthenic,  and  requires  stimulating  or  debilitating  treatment. 

As  for  Broussais,  what  does  he  care  that  cholera  differs  from  dothin- 
enteritis  in  its  form?  It  is  after  all  only  an  irritation  of  the  digestive 
tube  which  calls  forth  different  sympathies.  Irritation  is  the  common 
and  culminating  phenomenon;  it  is  the  only  serious  cause,  it  rules  all,  and 
from  it  spring  all  therapeutic  indications.  This  is  the  position  of  Brous- 
sais; we  have  not  attenuated  it;  we  have  left  it  in  its  full  strength,  but 
it  seems  to  us  none  the  less  weak. 

Doubtless,  most  of  the  modifying  agents,  applied  to  the  human  body, 
cause  a  common  local  reaction  which  has  been  by  common  consent  termed 
inflammation  or  irritation.  The  whole  question  is  reduced  to  this: 
whether  this  phenomenon  has  really  the  importance  which  has  been 
assigned  to  it.  No  doubt,  inflammation  is  a  common  character  in  malig- 
nant pustule  and  furuncle,  variola  and  impetigo,  syphilitic  chancre  and 
preputial  herpes,  acute  laryngitis  and  croup,  dothinenteritis  and  gastric 
oppression,  catarrhal  and  blennorrhagic  ophthalmia,  phagediT?nic  dartre 
and  varus  sebaceus,  as  there  are  characteristics  shared  in  common  by 
dulcamara  and  datura  stramonium,  chelidonium  and  poppy,  eglantine 
and  cherry-laurel,  since  they  belong  to  the  same  natural  families;  but 
what  physician,  what  naturalist,  would  be  so  deluded  as  to  attach  a 
merely  secondary  importance  to  their  specific  traits  ? 

Listen  to  M.  Bretonneau:  "The  obstinacy  of  a  physician,"  says  this 
excellent  practitioner,  "who  persists  in  seeing  in  bronchial  catarrh  and 
pellicular  angina  only  two  unimportant  shades  of  one  affection,  is  equal 


IRRITANTS    IN    GENERAL.  279 

to  that  of  a  naturalist  who  should  maintain  that  a  viper  is  only  a  variety 
of  adder,  and,  offering  in  proof  of  this  view  the  similarity  of  the  mode  of 
circulation  and  of  the  generic  marks  only,  should  regard  the  scales  and 
the  plates  which  cover  the  head,  and  the  absence  or  presence  of  venom- 
fangs,  as  unimportant  differences.  But  what  can  one  say  of  the  enemy 
of  distinctions,  when,  to  his  prejudiced  eye,  a  viper  and  a  rattlesnake  are 
only  exaggerated  adders?  AVhat  ground  can  one  take?  We  can  insist 
on  the  difference  of  the  effects  of  the  bites,  and,  while  waiting  for  truth 
to  shine  forth,  can  make  haste,  if  a  poisoned  wound  has  been  received,  to 
remove  the  cause  of  a  great  disease  by  cutting  out  a  little  piece  of  living 
tissue"  (Bretonneau:   "Notes  inedites  sur  les  phlegmasies  speciales"). 

The  physiologlsm  of  Brown  and  Broussais  is  not  so  remote  from  us  as 
might  at  first  be  thought;  if  it  has  changed  its  form  and  is  disguised 
under  the  name  of  variation  in  tension  of  vessels,  of  excitation  and  par- 
alysis of  the  vaso-motors,  it  is  still  the  strictum  and  laxum  of  Themison; 
formerly  it  was  a  property  common  to  all  our  organs,  at  the  beginning  of 
the  century  it  was  incarnated  in  the  tissues,  and  at  present  it  is  only  con- 
sidered in  the  vaso-motors.  It  is  still  the  theory  of  Themison,  dressed  in 
the  fashion  of  the  day. 

We  intentionally  lay  weight  on  the  question  of  the  specific  nature  of 
diseases,  because  this  question  rules  in  pathology,  and  we  could  not  make 
substitutive  medicine  understood  unless  we  had  previously  established 
the  great  pathological  principle,  that  "  a  special  modification  corresponds 
to  the  action  of  each  modifier." 

At  the  beginning  of  the  century  this  law  was  called  specificity;  it  is 
now  named  determinism. 

All  the  irritants  determine  an  irritation  of  a  severity  and  a  gravity 
which,  considering  the  lesion  as  local  or  as  general,  are  dependent  upon 
their  own  essential  nature;  that  is,  if  we  leave  out  constitutional  pecu- 
liarities. The  attentive  pathologist  may  calculate  to  a  certain  point  the 
reach  of  the  irritant,  and  when  he  cannot  grasp  the  cause,  he  may  never- 
theless, by  experience  and  the  application  of  medical  statistics,  estimate 
the  probable  duration  or  the  gravity  of  a  phlegmasia.  He  sees  that  some 
have  a  necessary  and  fated  course;  that  they  arise,  grow  and  end  at  a 
determined  time;  that  others,  uncertain  in  duration,  in  some  cases  have 
an  ephemeral  duration,  in  others  are  irresistibly  prolonged  to  the  end  of 
life,  and  in  others  appear  and  disappear  without  any  regularity  in  their 
progress. 

A  truly  learned  physician,  therefore,  knows  pretty  well  the  probable 
duration  and  the  natural  course  of  a  disease.  This,  the  most  important 
notion  for  the  therapeutist,  without  which  he  cannot  philosophically  make 
the  least  experiment,  is  most  neglected  in  clinical  study.  It  is  the  ele- 
ment which  is  essentially  lacking  in  all  homoeopathic  physicians. 

The  progress  and  duration  of  a  phlegmasia  being  known,  if  we  could 
place  in  contact  with  the  inflamed  tissue  a  modifying  agent,  itself  an 
irritant,  which  should  change  the  mode  of  irritation  and  shorten  the  dura- 


280  THERAPEUTICS. 

tion  of  the  disease,  should  we  not  be  rendering  a  great  service  to  thera- 
peutics by  this  substitution  ? 

Now,  is  this  a  fair  statement  ?  Evidently  it  is.  The  conjunctiva  is 
inflamed;  a  collyrium  of  sublimate,  nitrate  of  silver,  calomel,  red  precipi- 
tate, irritating  the  inflamed  part  for  a  moment,  cures  the  inflammation. 

The  fact  being  established,  let  us  study  its  laws. 

And  first,  although  substitution  can  be  practised  mediately,  that  is, 
through  the  absorbents,  upon  tissues  with  which  the  irritants  are  not  in 
direct  contact,  we  restrict  our  attention  to  direct  substitution,  that  is, 
that  which  is  exercised  by  the  irritants  applied  directly  to  the  irritated 
tissues. 

The  first  thing  to  be  established  is  the  gravity  and  the  natural  course 
of  the  disease.  Next,  the  influence  of  the  modifvin2:  accent  must  be 
ascertained;  for  it  is  above  all  necessary  that  the  substituted  disease  be 
not  worse  than  the  one  replaced.  For  example:  agents  which  destroy 
the  tissues  by  chemical  or  physical  action  are  wonderfully  adapted  to 
disperse  the  lesions  of  these  tissues;  but  destroying  is  not  curing,  and 
if  the  physician  is  sometimes  forced  to  such  measures,  it  is  only  when 
the  local  disease  is  so  grave  and  incurable  that  destruction  is  indispen- 
sable. 

But  the  therapeutic  effect  of  the  agent  can  hardly  be  anticipated,  and 
experience  alone  can  inform  us  how  the  vital  properties  react  against  the 
irritant  cause.  There  seems  to  be  a  notable  difference  between  quick-lime 
which  makes  an  eschar  in  a  few  minutes,  and  the  more  slowly  acting 
butter  of  antimony;  one  would  be  tempted  to  think  that  the  action  of 
lime  would  be  more  painful  than  that  of  the  chloride,  but  experience 
shows  the  contrary;  and  in  many  local  inflammations  which  are  usually 
called  spontaneous,  and  which  differ  from  others  only  in  conditions  which 
are  wholly  independent  of  the  cause,  this  difficulty  in  judging  reappears. 
At  the  beginning  of  two  anginas,  in  one  of  which  there  is  a  slight  local 
inflammation  with  a  membranous  exudation  and  hardly  any  fever,  and  in 
the  other  the  most  energetic  symptoms  of  inflammation  and  general  reac- 
tion, it  seems  natural  to  think  the  one  most  severe  which  strikes  hard- 
est; and  yet,  while  the  latter  does  hardly  more  than  to  occasion  a  few 
days'  discomfort,  the  former  almost  always  kills  by  the  septic  and  de- 
structive nature  of  its  principle. 

The  gravity  of  an  irritation  is  judged  neither  from  the  nature  of  the 
pain,  nor  the  order  of  appearance  of  the  symptoms,  nor  their  rapidity  of 
development.  If  a  concentrated  solution  of  tartar  emetic  is  dropped  into 
the  eye,  only  a  slight  stinging  is  felt;  but  if  a  grain  of  snuff  falls  in,  the 
most  violent  irritation  ensues,  lasting  for  only  a  few  minutes,  while  in  the 
other  case  the  eye  is  slowly  injected,  becomes  inflamed,  and  the  severest 
ophthalmia  soon  appears,  often  followed  by  loss  of  the  eye. 

The  severity  and  the  course  of  therapeutical  inflammations,  if  we  may 
so  speak,  are  known  only  by  experience,  as  in  the  case  of  pathological  in- 
flammations. 


IRRITANTS    IN    GENERAL.  281 

Therefore,  before  using  substitutive  treatment,  we  ought  to  know  the 
range  of  our  weapons. 

Some  of  the  irritants  have  a  very  short  range;  they  produce  very 
transient  effects;  such  are  the  nitrate  of  silver,  sulphate  of  zinc,  nitrate 
of  mercury,  calomel,  and  the  alkaline  chlorides  ;  of  others  the  effects  are 
much  less  fleeting,  as  cantharides,  tartarized  antimony,  arsenic,  the 
strong  caustics,  mustard,  the  euphorbiaceee,  the  ranunculacea?,  the  colchi- 
caceje. 

As  it  is  always  necessary  to  proportion  the  intensity  of  the  action  of 
the  substitutive  agent  to  the  inflammation,  it  would  be  absurd  to  attack 
superficial  lesions  with  agents  of  the  second  series,  which  are  suitable  for 
grave,  deep,  or  chronic  lesions  of  tissue.  Thus,  malignant  pustule  and 
the  variolous  pustule  are  destroyed  by  a  caustic;  and  superficial  carci- 
noma of  the  skin,  which  is  aggravated  by  superficial  irritation,  is  destroyed 
by  caustics  that  take  off  the  whole  thickness  of  the  derma,  or  by  irritants, 
like  arsenic,  which  have  a  deep  and  prolohged  action. 

Two  mistakes  must  be  avoided  in  proportioning  the  substitutive 
action  to  the  exciting  irritation;  we  must  neither  do  too  much  nor  too 
little. 

It  generally  does  little  harm  to  do  too  little;  one  may  even,  by  follow- 
ing this  prudent  path,  attain  the  same  end,  if  the  action  is  kept  up  and 
repeated.  Suppose  a  blennorrhagia  of  the  urethra,  which  we  wish  to 
cure  with  injections  of  nitrate  of  silver.  We  begin  with  a  weak  solution; 
1  part  in  3,000  of  distilled  water  produces  a  slight  therapeutical  irritation 
which  will  not  control  the  syphilitic  phlegmasia,  but  will  substitute  itself 
for  a  part  of  it,  so  that,  to  use  an  inexact  representation,  we  have  a  blen- 
norrhagic  irritation  represented  by  10,  and  a  substitutive  represented  by 
3.  The  substitutive  not  being  proportionate  to  the  irritation,  the  latter 
remains  8;  but  if  we  prolong  the  contact  of  the  irritant  solution,  we  may 
make  up  for  its  weakness  by  time. 

This  method  is  the  more  rational,  as  it  is  impossible  to  know  before- 
hand the  sensibility  of  the  tissues,  and  as  it  is  better  to  have  to  increase 
the  irritation  than  to  lessen  it,  when  it  has  rashly  been  made  excessive. 

We  said  that  each  agent  had  its  own  range.  The  duration  of  action 
varies  from  a  few  hours  to  some  days,  according  to  the  intimate  nature 
of  the  modifier  and  the  dose  used. 

The  morbid  irritation,  as  pre-existent,  and  as  having  deeply  modified 
the  tissue  by  simple  duration,  has  acquired  a  sort  of  right  of  domi- 
cile, and  a  great  tendency  to  reproduce  itself.  If  the  substitute  acts  only 
six,  twelve,  or  twenty-four  hours,  it  may  replace  the  inflammation  for 
that  period;  but  if  it  be  left  off  at  once,  the  primitive  condition  returns. 
In  order  to  produce  effective  substitution,  the  action  must  be  renewed 
before  the  effect  of  the  former  application  is  entirely  gone, 

Thus,  when  dysentery  is  treated  with  injections  containing  nitrate  of 
silver  or  neutral  purgative  salts,  the  pain,  the  colic  and  the  bloody  flow 
are  lessened  by  the  first  injections;  but  they  aj^pear  again  in  a  week  or 


282  THERAPEUTICS. 

ten  days;  the  rule  here  is,  not  to  wait  till  the  return  of  the  dysenteric 
symptoms,  but  to  renew  the  injections  so  often  as  to  keep  the  patient  con- 
tinually under  their  action. 

Assuming,  as  we  have  done  hitherto,  that  all  the  patients  are  in  iden- 
tical conditions,  and  that  no  individual  peculiarities  come  in  play,  it  is  evi- 
dent that  the  substitutive  irritation  will  be  proportionate  to  the  dose  of 
the  agent.  But  it  is  necessary  to  attend  to  what  Brown  called  the  ex- 
haustion of  incitability,  in  order  not  to  use  the  remedy  in  vain. 

According  to  Brown,  each  organic  element  has  assigned  to  it,  as  to  the 
entire  system,  a  fundamental  property — incitability.  Stimulants  develop 
incitation;  but  in  this  process  the  capacity  for  incitation,  or  incitability, 
becomes  exhausted.  It  follows  that  the  physician's  part  ought  to  be  to 
restore  incitability  by  rest,  food,  etc.,  that  the  same  stimulant  may  always 
produce  the  same  incitation;  or  else  to  increase  the  action  of  the  inci- 
tant,  in  order  that  the  incitation  may  remain  the  same,  though  incitability 
is  lowered.  In  fact,  this  amounts  to  saying  that  the  tissues  and  the  sys- 
tem get  accustomed  to  the  various  stimulants,  and  consequently  are  no 
longer  excited  by  the  agents  which  formerly  so  acted;  that  in  conse- 
quence, in  order  to  obtain  the  same  result  daily,  the  power  of  the  exci- 
tant must  be  increased  just  in  proportion  to  the  diminution  of  organic 
susceptibility.  The  consequence  of  these  principles  is,  that  the  dose  of 
the  substitutive  agent  must  be  gradually  increased,  not  at  an  equal  rate 
for  all  patients  and  cases,  but  in  a  proportion  to  be  determined  by  experi- 
mental study  of  the  patient's  irritability.  ^ 

From  this  great  pathological  law  of  Brown's  there  springs  another  es- 
sential application  of  substitution  in  acute  or  chronic  diseases. 

Doubtless  the  habit  of  inflammation  in  a  tissue  renders  the  tissue 
more  apt  to  receive  the  same  inflammation,  but  less  apt  to  take  foreign 
impressions.  So,  other  things  being  equal,  a  more  energetic  irritant  is  re- 
quired in  a  chronic  than  in  an  acute  disease,  and  the  importance  of  this 
rule  becomes  more  evident  when  we  think  that,  in  addition  to  the  loss  of 
incitability,  a  necessary  consequence  of  chronicity,  we  have  also  to  strive 
against  a  prolonged  vicious  direction  of  the  vital  properties  of  the  part, 
and  against  a  deeply  rooted  disease;  while  in  acute  inflammations  the 
substitution  not  only  costs  less,  but  does  not  require  to  be  kept  up  so 
long. 

Our  remark  upon  the  necessity  of  sustaining  an  impression,  to  prevent 
the  disease  from  regaining  its  hold,  leads  to  another  precept  which  is,  in 
a  sense,  the  corollary  of  the  former,  namely,  that  we  must  not  only  repeat 
the  action,  but  prolong  it  so  as  to  cause  the  tissue  to  lose  entirely  the 
former  habit  of  inflammation;  the  action  of  irritants  must  sometimes  be 
kept  up  for  weeks. 

We  laid  dow-n  a  rule,  never  to  remove  an  ordinary  inflammation  at 
once;  but  some  bolder  physicians,  after  making  a  few  preliminary  trials 
to  ascertain  the  susceptibility,  double,  treble,  decuple  the  violence  of  the 
irritant,  replacing  the  inflammation  forcibly  by  a  new  therapeutic  inflam- 


IRRITANTS    ITS'    GENERAL.  283 

mation.  This  is  not  always  very  prudent;  but,  while  we  are  disposed  to 
object  to  it  in  common  cases,  we  desire  to  make  it  a  principle  in  local  dis- 
eases, the  severity  of  which  may  in  a  few  hours  compromise  life  or  the 
health  of  an  organ.  We  ought  to  cauterize  malignant  pustule  and  its 
surroundings  as  quickly  as  possible,  and  to  apply  lapis  infernalis  to  the 
conjunctiva  when  attacked  by  blennorrhagia. 

Substitutive  irritation  must  not  be  confounded  with  morbid  inflamma- 
tion, nor  vice  versa.  It  is  rather  worse  to  obtain  too  little  than  too  much 
effect.  If  the  inflammation  is  kept  up  by  persistence  in  the  remedy,  it  is 
sufficient,  in  order  to  cure,  to  stop  all  treatment;  while,  if  the  primary 
inflammation  were  still  in  existence,  and  were  allowed  to  acquire  force  by 
a  momentary  suspension  of  treatment,  the  latter  would  have  to  be  recom- 
mended. 

Let  us  seek  to  establish  a  criterion,  whereby  we  may  decide  whether 
the  remaining  inflammation  belongs  to  the  disease  or  the  remedy. 

When  an  irritant  is  applied  to  an  inflamed  tissue,  the  symptoms  of  in- 
flammation are  usually  either  increased  at  once,  or  experience  a  more  or 
less  considerable  diminution. 

If  experience  shows  that  the  morbid  secretion,  the  pain,  or  itchino-,  are 
lessened  under  the  influence  of  the  irritant,  the  return  of  such  symptoms 
will  mark  the  return  of  the  inflammation  and  the  cessation  of  substitutive 
action.  If,  on  the  contrary,  the  substitute  causes  a  marked  increase  in 
the  pain,  the  secretion,  the  itching,  etc.,  then  a  diminution  in  these  symp- 
toms will  indicate  the  necessity  of  recurring  to  the  modifying  agent. 

The  former  point  is  very  easy  to  decide;  but  the  latter  is  so  hard  that 
we  think  it  impossible  to  be  guided  except  by  the  long-tried  results  of 
experience. 

In  the  majority  of  cases  we  do  not  try  to  remove  the  inflammation  at 
a  blow,  and  we  cannot  suppose  the  substitution  to  be  complete;  if,  there- 
fore, after  twenty-four,  forty-eight,  or  seventy-two  hours,  we  find  a  de- 
cided diminution  of  the  primary  symptoms,  we  may  infer  that  the  remedy 
is  acting,  and  that  we  may  resume  it;  and,  although  the  inflammatory 
symptoms  which  appear  immediately  under  the  influence  of  the  agent  are 
indistinguishable  from  those  of  pathological  irritation,  we  shall  have  no 
other  guide  than  the  results  of  experience  and  analogy,  which  may  be 
relied  on  with  more  certainty  than  rules  which  are  subject  to  too  many 
exceptions. 

The  Brownian  principle  which  we  stated,  or,  if  preferred,  the  study  of 
the  influence  of  habit,  lead  to  other  therapeutical  consequences.  We  have 
seen  that  the  habitual  use  of  stimulants  lessens  the  incitability  of  a  part. 
It  follows  that  the  habitual  application  of  stimulants  is  a  useful  prophy- 
lactic against  local  irritation.  This  is  well  known  to  women  who  employ 
for  the  cure  or  prevention  of  acne  rosacea,  irritant  lotions  containing  sub- 
limate, or  simply  very  hot  Avater.  Do  we  not  see  the  habit  of  warm  in- 
jections extinguish  the  sensibility,  the  contractility,  and  the  secreting 
power  of  the  intestine,  just  as  the  habitual  use  of  highly-seasoned  food 


284  THERAPEUTICS. 

and  gastric  stimulants,  far  from  producing  gastritis,  leaves  tlie  mucous 
membrane  of  the  stomach  in  a  state  of  organic  insensibility  which  para- 
lyzes all  its  functions.  This  truth  was  admirably  shown  by  Brown,  but 
ill  appreciated  by  Broussais.  In  this  way,  workmen  who  are  constantly 
exposed  to  a  strong  heat,  far  from  having  complexions  like  the  people  of 
the  north,  are  remarkable  for  extreme  pallor,  as  cooks,  bakers,  glass-blow- 
ers, charcoal-burners,  etc.,  and  the  inhabitants  of  tropical  climates.  Those 
who  specially  treat  disease  of  the  skin  know  the  immense  value  of  the  ap- 
plication of  caloric,  not  less  as  a  preventive  than  as  a  curative. 

Hitherto  we  have  paid  little  attention  to  the  cause  of  the  phlegmasia, 
and  have  treated  it  as  if  it  were  always  of  internal  origin.  Nor  have  we 
mentioned  the  state  of  the  system.  AVe  have  made  the  omission  purposely, 
and  certainly  no  otie  will  be  led  to  think  that  we  neglect  the  importance 
of  external  causes.  In  internal  inflammations  the  cure  of  the  cause  is 
sometimes  the  principal  point;  in  other  circumstances,  this  cause  may  be 
neglected  without  inconvenience.  In  most  of  the  cutaneous  syphilidae  the 
internal  treatment  is  almost  always  sufficient,  and  topical  treatment  is  al- 
most superfluous;  while  in  almost  all  dartres  the  internal  treatment  is 
secondary,  and  the  direct  agents  hold  the  first  place. 

Admitting  that  the  dartrous  inflammation  proceeded  from  an  internal 
cause,  it  would  not  follow  that  we  ought  to  confine  our  attention  to  that 
cause,  for  the  cause  may  have  ceased  to  act,  Avhile  the  local  disease  con- 
tinues, exactly  as  the  irritation  may  last  long  after  the  application  of  an 
external  irritant  agent. 

The  choice  of  the  agent  ought  to  be  influenced  in  some  degree  by  the 
internal  cause,  however  inactive  it  may  have  become.  For  instance,  ni- 
trate of  mercury  must  be  preferred  to  nitrate  of  silver  in  syphilitic  in- 
flammation; the  preparations  of  iodine  to  the  salts  of  copper  in  scrofulous 
dartres,  because  each  organic  molecule  is  a  sort  of  microcosm  representing 
tlie  general  condition. 

The  applications  of  substitutive  local  treatment  are  innumerable.  Most 
of  the  acute  and  chronic  diseases  of  the  skin,  considered  as  local  affections, 
are  under  the  jurisdiction  of  this  great  method;  and  the  same  is  true  of 
diseases  of  the  mucous  membranes. 

The  treatment  of  traumatic  erysipelas  by  ointment  of  nitrate  of  sil- 
ver, of  acute  eczema  by  vapor-baths,  sublimate,  or  washes  of  phagedsenic 
water;  the  use  of  mercurial  plasters  upon  the  face  in  small-pox;  the 
washes  and  ointments,  alkaline,  sulphurous  or  mercurial,  in  most  herpetic 
maladies;  the  use  of  very  warm  lotions,  and  vapor-douches  at  a  very 
high  temperature,  in  many  chronic  affections  of  the  skin,  are  all  applica- 
tions of  substitutive  treatment. 

In  the  treatment  of  acute  and  chronic  diseases  of  the  mucous  mem- 
brane, these  applications  are  still  more  frequent. 

In  ophthalmia,  and  diseases  of  the  nasal  mucous  membrane,  nitrate 
of  silver,  sulphate  of  copper,  sulphate  of  zinc,  calomel,  red  precipitate, 
and  very  hot  water,  are  used. 


IRRITANTS    IN    GENERAL.  285 

In  stomatitis,  and  the  severest  and  most  obstinate  angina,  muriatic 
and  nitric  acids,  dry  chloride  of  lime,  calomel,  alum,  sulphate  of  copper, 
nitrate  of  silver. 

In  croup  and  whooping-cough,  cauterization  of  the  upper  part  of  the 
larynx;  in  chronic  affections  of  the  larynx  and  bronchi,  inhalation  of  va- 
pors of  arsenic,  muriatic  acid,  mercur^^,  iodine. 

In  acute  or  chronic  colitis,  calomel,  injections  of  nitrate  of  silver,  of 
irritant  salts,  of  sulphuret  of  potassium;  the  various  injections  which  are 
thrown  into  the  urethral  canal  and  the  bladder;  perhaps  the  action  of 
ipecac,  of  emetics,  of  certain  purgatives  in  gastro-intestinal  inflammation, 
and  of  the  balsams  in  mucous  flux. 

This  important  method  of  treatment  can  only  be  summaril}-  stated  here; 
its  applications  in  detail  are  given  under  the  individual  remedies. 


Tkaxspositia^e  Irrit-axt  Treatmekt. 

When  two  physiological  or  pathological  acts  of  a  certain  value  are 
performed  at  one  time,  the  stronger  one  weakens  the  other.  This  is  the 
interpretation  of  the  celebrated  aphorism  of  Hippocrates:  "Duobus  la- 
boribus  simul  obortis,  non  eodem  loco,  vehementior  obscurat  alterum." 
On  this  principle  rests  transpositive  treatment.  The  problem  is  as  fol- 
lows: "Given  a  severe  lesion,  to  produce  artificially,  in  another  place,  a 
more  energetic  and  less  dangerous  lesion,  in  order  to  attenuate  the  for- 
mer." 

The  possibility  of  transposition  is  subordinate  to  circumstances  which 
it  is  very  important  to  state  here,  relative  to  the  nature,  seat,  and  extent 
of  the  disease. 

JRelative  to  the  nature  of  the  disease. — Some  local  lesions  hardly  change 
the  texture  of  the  organs,  and  are  so  mobile  that  they  change  their  seat 
at  the  slightest  perturbation.  Among  these  are  included  neuralgias  which 
have  not  involved  inflammation  of  the  nerve,  rheumatism  at  its  outset, 
the  congestions  and  certain  inflammations  of  the  skin,  such  as  urticaria, 
roseola,  measles,  etc. 

Other  lesions  are  marked  by  a  very  great  adhesion  to  the  organs,  so 
great  that  sometimes  no  treatment  overcomes  it.  Such  are  the  eruptions 
of  small-pox,  most  of  the  parenchymatous  inflammations  and  organic  de- 
generations. 

Whatever  attempt  we  may  make  with  revulsives  to  arrest  the  prog- 
ress of  a  pneumonia,  a  hepatitis,  a  pustular  eruption  of  the  skin  or  mu- 
cous membranes,  we  shall  never  succeed;  the  disease  takes  its  course, 
unless  other  remedies  are  used.  But,  in  the  lighter  affections  of  which 
we  just  spoke,  an  irritation  applied  to  the  skin  or  a  mucous  membrane 
often  suffices  to  transpose  the  irritation. 

JRelative  to  the  seat  of  the  disease. — The  acute  phlegmasia?  of  the 
mucous  membranes  are  more  generally  rheumatoid  or  catarrhal — that 


286  THERAPEUTICS. 

is,  the  irritation  is  transient,  superficial,  not  tenacious;  while  in  the 
parenchymata  it  is  more  obstinate  and  profound.  This  is  doubtless  due 
to  the  facility  with  which  irritant  secretions  unload  the  tissue,  while  in 
the  parenchyma  the  secretions  are  retained  to  become  the  cause  of  a 
fresh  irritation.  Whatever  may  be  the  explanation,  experience  shows 
that  the  transposition  is  easily  made  from  a  mucous  membrane  to  the 
skin  or  another  mucous  membrane.  Catarrhal  angina  often  yields  with 
extraordinary  rapidity  to  an  emetic,  a  purge,  a  simple  sinapism;  and  so 
with  certain  forms  of  bronchitis,  coryza,  gastritis,  enteritis,  and  colitis; 
in  this  case  the  irritation  of  the  mucous  membrane  is  probably  rheuma- 
tismal  in  character.  One  equally  advantageous  result  does  not  follow, 
even  in  slight  phlegmasiae  of  the  parenchyma.  The  transposition  is  not 
so  easy  in  parenchymatous  affections,  except  when  the  irritation  has  pro- 
duced only  congestion,  or  when  the  acute  symptoms  are  already  dissipated. 

Relative  to  the  age  of  the  j^dtient. — Not  all  the  phlegmasia?  have  an 
invincible  tendency  to  suppuration  like  the  variolous  inflammation  of  the 
skin.  Some  can  be  checked  without  very  great  difficulty,  and  have  not  a 
predetermined  course.  We  do  not  doubt  that  in  many  cases  pleurisy  be- 
gins and  is  aborted  quite  unknown  to  the  physician;  that  it  is  the  same 
in  pneumonia  and  inflammation  of  the  tonsils.  In  this  case  nothing  but 
a  simple  congestion  exists,  due  to  a  local  irritation  or  a  general  cause. 
There  is  as  yet  no  such  local  lesion  as  to  cause  any  great  sympathetic 
trouble;  a  slight  diarrhoea,  an  epistaxis,  an  abundant  sweat,  a  footbath, 
conjure  a  disease  which  would  probably  have  been  severe  if  the  transpos- 
itive  irritation  had  not  been  developed  at  a  remote  part. 

But  if  an  irritation  causes  something  more  than  simple  congestion,  and 
a  true  inflanunatory  fluxion  exists,  the  irritants  can  seldom  displace  the 
inflammation;  they  usually  aggravate  it  unless  the  revulsives  are  very 
powerful  or  the  inflammation  very  light,  Velpeau  caused  diffused  phleg- 
mons of  the  leg  to  abort  by  covering  it  almost  entirely  with  a  blister;  and 
it  was  formerly  the  custom  with  certain  physicians  to  cover  the  chest 
with  an  enormous  blister  in  all  periods  of  pleurisy  and  pneumonia,  where- 
by they  often  aborted  the  inflammation.  This  is  also  the  practice  of  M. 
Gendrin,  who  thinks  highly  of  it.  But  it  is  a  practice  which  we  should 
not  dare  to  apply,  and  which  we  should  never  advise  unless  a  well  estab- 
lished experience  showed  its  value. 

When  the  acute  stage  of  inflammation  is  past,  if  the  fluxion  persists,  and 
the  other  inflammatory  symptoms  do  not  disappear,  we  may  infer  that  the 
irritation  no  longer  exists,  and  may  then  employ  revulsives  to  advantage. 

As  the  occasion  offers,  we  owe  it  to  our  readers  to  explain  ourselves 
clearly  upon  the  preceding  paradoxical  statement. 

The  physiological  school  presume  the  inflammation  to  exist  until  all 
the  inflammatory  symptoms  are  past;  we  believe  that  there  may  be  little 
or  no  irritation  at  a  period  when  certain  inflammatory  symptoms  are  at 
their  height. 

We  do  not  think  that  the  primary  results  of  irritation  have  been  suffi- 


IRRITANTS    IN    GENERAL.  287 

ciently  distinguished  from  the  secondary;  the  immediate  consequences  are 
increased  vascularity  (sanguineous  congestion),  the  consequent  swelling, 
pain  and  heat.  But  what  would  become  of  these  symptoms  if  the  irrita- 
tion were  to  cease  at  once?  Swelling  and  pain  would  remain,  while  the 
active  fluxion  and  the  heat  would  disappear  almost  immediately.  Swell- 
ing would  remain,  because  morbid  products  would  be  effused  in  the  pa- 
renchymatous framework  or  the  cellular  tissue,  and  pain,  because  of  the 
mechanical  distention;  just  as  when  an  irritation  of  the  pleura  or  perito- 
neum wholly  ceases,  we  may  yet  find  abundant  morbid  products  in  the 
serous  cavity,  though  the  cause  for  them  has  long  disappeared.  Thus, 
two  of  the  most  capital  phenomena  of  inflammation,  swelling  and  pain, 
may  exist  in  a  high  degree  without  irritation. 

We  suppose  a  sudden  disappearance  of  irritation.  Though  this  hy- 
pothesis may  sometimes  be  realized,  it  is  quite  rare  ;  irritation  usually 
goes  gradually,  and  the  inflammatory  phenomena  afterwards  depart  read- 
ily. But  a  slight  irritation  may  inhere  in  the  part,  and  become  a  con- 
stant cause  of  afflux  of  fluids,  and  of  other  symptoms  of  chronic  inflamma- 
tion; in  this  case  transpositive  revulsion  must  be  long  continued,  until 
the  part  has  lost  the  habit  of  suffering. 

Thus,  transpositive  medicine  is  indicated  in  the  beginning  of  phleg- 
masias  when  only  congestion  and  a  moderate  inflammation  are  present; 
it  is  usually  prescribed  in  the  height  of  the  attack,  and  is  reapplied  when 
there  is  reason  to  suppose  that  the  inflammation  has  become  less  intense, 
even  when  the  swelling  or  effusion  are  not  diminished. 

Relative  to  the  extent  of  the  disease. — If  the  morbid  state  were  one, 
transposition  would  always  be  easy,  in  inverse  ratio  to  the  extent  of  the 
disease;  it  may  be  stated  as  a  principle  that  this  is  the  case  when  we  have 
only  similar  lesions  to  deal  with;  but  the  extent  is  a  less  important  thing 
to  consider  than  the  nature  and  duration. 

A  catarrh  covering  an  immense  surface  of  mucous  membrane  may  be 
transposed  with  ease,  but  the  most  energetic  revulsion  is  powerless  over 
a  little  ulceration  or  the  most  simple  dartre.  Before  employing  the  re- 
vulsive, we  must  know  by  experience  what  inflammations  can  be  trans- 
posed; after  this,  we  must  proportion  the  extent  of  the  application  to  the 
extent  of  the  inflammation.  The  neglect  of  this  principle  is  the  reason 
why  revulsion  has  fallen  into  discredit. 

In  suffocative  bronchitis  a  small  blister  is  put  to  the  leg  or  sternum, 
and  if  relief  is  not  immediate,  the  weakness  of  the  remedy  is  blamed,  in- 
stead of  the  unskilfulness  of  the  physician.  How  can  a  bronchial  phleg- 
masia, occupying  perhaps  some  square  metres  of  surface,  be  drawn  away 
by  a  blister  of  some  centimetres'  surface  ? — one  may  as  well  expect  a  se- 
vere congestion  of  the  chest  to  be  relieved  by  the  letting  of  a  few  grammes 
of  blood.  We  must  do  what  Velpeau  did  so  successfully.  He  knew  that 
the  treatment  must  be  proportioned  to  the  intensity  and  the  extent  of  the 
inflammation,  and  we  have  seen  him  arrest  deep  phlegmons  which  threat- 
ened frightful  results,  by  blisters  which  covered  an  entire  limb.     Thus  is 


288  THERAPEUTICS. 

explained  the  success  of  M.  Gendrin,  who  does  not  shrink  from  covering- 
one  whole  side  of  the  chest  with  an  enormous  blister  at  the  beginning 
and  the  heig"ht  of  a  pleurisy  or  pneumonia. 

The  want  of  extension,  in  transpositive  inflammation,  is  made  good  by 
the  intensity  of  the  action.  We  need  not  despair  of  deriving  a  capillary 
bronchitis,  though  it  be  impossible  to  blister  a  surface  as  large  as  the  out- 
spread bronchi,  for  we  may  by  cantharides  inflame  the  skin  to  a  great 
depth  and  thus  make  intensity  compensate  for  extension. 

Relative  to  the  nature  of  the  disease. — It  is  impossible  to  transfer  a 
phlegmonous  inflammation  to  another  point,  and  the  same  is  true  of  cer- 
tain specific  inflammations.  We  may  try  in  vain  to  drive  away  a  syphili- 
tic chancre,  or  a  diphtheritic  angina  with  a  blister.  Dartres  in  the  adult, 
and  the  rashes  called  gourmes  [crusta  lactea]  in  children,  are  in  the  same 
case.  Blisters  and  issues  are  a  standard  remedy  in  gourmes  and  dartres; 
it  is  most  important  to  study  their  influence  upon  these  affections. 

Let  us  recall  certain  facts. 

An  irritant  application  made  to  the  skin  often  causes  a  general  phleg- 
masia of  that  organ;  a  Burgundy  pitch  plaster,  having  caused  the  local 
development  of  a  great  number  of  vesicles,  sometimes  occasions  a  general 
eczema,  at  first  acute,  which  may  afterwards  become  chronic.  The  ap- 
plication of  croton  oil  or  mercurial  ointment  may,  in  certain  cases,  pro- 
duce the  same  accidents. 

But  few  years  pass  in  a  hospital  with  female  patients,  without  an  ex- 
plosion of  eczema  due  to  a  badly  dressed  blister.  In  1840  we  had  a 
female  patient  in  the  Hopital  Necker  to  whose  thigh  we  ordered  the  ap- 
plication of  a  flying-blister  to  cure  a  rheumatism;  it  was  dressed  with 
gummy  diachylon  plaster.  A  few  days  later  there  appeared  around  the 
sore  a  vesicular  eruption  which  soon  invaded  the  whole  surface  of  the 
body,  causing  high  fever;  this  condition  became  gradually  quieted,  but 
was  replaced  by  a  pemphigus  which  lasted  some  months  and  required  the 
long-continued  use  of  sublimate  baths.  We  lately  applied  to  an  old 
woman's  temples  two  ammoniacal  blisters  for  temporo-facial  neuralgia; 
they  were  dressed  with  diachylon,  and  in  a  few  days  an  eczema  appeared 
on  the  forehead,  and  soon  the  face,  neck,  and  arms  were  invaded,  and  the 
accidents  were  not  calmed  without  great  difficulty. 

This  singular  tendency  to  contract  cutaneous  phlegmasias,  very  rare 
in  men,  but  a  little  less  so  in  women,  is  common  in  children.  How  often 
have  we  seen,  both  in  and  out  of  hospitals,  an  acute,  simple,  or  impetigi- 
nous eczema  attack  a  poor  child  after  the  application  of  a  flying-blister  to 
relieve  pneumonia?  The  affection  is  mostly  chronic;  and,  considering 
that  the  children  had  previously  no  cutaneous  troubles,  we  must  admit 
that  the  blister  was,  if  not  the  full  and  radical  cause,  at  least  the  occa- 
sional cause  of  the  manifestation  of  the  disease. 

We  may  then  state  formally,  that  the  blister  often  gives  rise  to 
"  gourmes."  Hence,  as  a  preventive  of  such  rashes,  it  often  fails,  and 
even  frustrates  its  own  end. 


IRRITANTS    IN    GENERAL.  289 

If  we  arc  accustomed  to  young  children,  we  may  be  able  to  guess  be- 
forehand whether  the  skin  will  become  widely  inflamed  after  the  application 
of  a  blister  or  any  other  agent  capable  of  producing  active  aiid  persistent 
local  phlegmasia.  Such  a  prediction  may  be  erroneous,  but  it  enables 
the  practitioner  to  be  on  his  guard. 

We  must  not  use  blisters  as  a  preventive  of  gourmes  upon  blond  or 
red-haired  children,  with  a  very  fine  white  skin  and  very  red  cheeks,  nor 
upon  those  who  chafe  and  suppurate  when  not  strictly  cared  for,  nor 
those  whose  parents  are  dartrous.  We  must  not  leave  a  blister  upon 
those  whose  skin  becomes  irritated  around  the  sore. 

We  have  seen  in  our  wards  at  the  Hopital  Necker  a  young  child 
which  had  had  a  slight  lichen  for  several  months  and  limited  to  a  few 
points  of  the  skin;  a  physician  ordered  a  permanent  blister,  and  in  a  few 
days  the  arm  to  which  the  exutory  was  applied  was  covered  with  an 
eczematous  eruption,  which  soon  invaded  the  entire  body. 

We  have  seen  many  children  affected  with  gourmes;  in  accordance 
with  routine  and  theories,  we  have  applied  permanent  vesicatories;  we 
have  often  had  to  repent  and  very  rarely  to  be  pleased  with  the  treat- 
ment. 

In  general,  blisters  must  be  forbidden  in  such  cases.  But  they  are 
not  forbidden  in  the  cases  we  are  about  to  specify. 

We  forbid  them  when  the  rash  is  cutaneous. 

We  usually  advise  them  when  the  mucous  membranes  are  affected. 

We  forbid  in  the  former  case,  because  experience  shows  that  if  the 
rash  is  on  the  skin,  the  blister  makes  simply  one  point  more,  without  any 
benefit  as  regards  the  other  points. 

We  advise  it  in  the  second,  because  experience  shows  us  that  a  cuta- 
neous trouble  behind  the  ears,  or  on  the  scalp,  very  often  alternates  with 
an  ophthalmia  or  a  chronic  eczema  of  the  nasal  fossre,  as  if  there  were  an 
incompatibility  between  them.  In  this  case  the  application  of  a  blister 
to  the  arm  is  commonly  useful,  though  sometimes  the  disease  remains 
obstinately  in  its  old  seat  and  refuses  to  take  the  new  road.  In  this 
case  we  may  give  up  the  permanent  blister,  but  not  hesitate  to  call  the 
fluxion  to  the  point  where  it  most  readily  and  most  beneficiall}'  places 
itself. 

But  if  the  blister  is  useful  in  alternative  rashes  (to  use  a  rather  incor- 
rect expression),  it  is  no  longer  so  when  the  rash  which  invades  the  mu- 
cous membrane  is  propagated  from  the  skin,  instead  of  being  a  compensa- 
tion for  it. — We  have  often  seen  an  impetiginous  eczema  gradually  invade 
the  forehead,  the  eyelids,  the  conjunctiva,  the  rest  of  the  face,  and  jDene- 
trate  within  the  nose;  this  we  call  a  propagation.  Here  the  blister  does 
not  succeed.  But  when  the  ophthalmia  takes  the  place  of  eczema  of  the 
skin,  which  again  takes  the  upper  hand  when  the  ophthalmia  ceases,  we 
have  alternation,  compensation  in  some  sense;  in  this  case  the  blister  is 
commonly  useful. 

But  if  useful  in  those  seesaw  rashes,  the  blister  is  imperativelv  de- 
19 


290  THERAPEUTICS. 

manded  in  bronchitis,  enteritis,  and  pulmonary  or  intestinal  catarrh,  dis- 
eases which,  alternating  with  skin-rashes,  are  truly  the  manifestation  of 
the  same  diathesis — which  a  true  pathologist  should  never  forget. 

Mode  of  action  of  trunspositant  agents. — It  would  greatly  embarrass 
us  to  have  to  say  by  what  internal  paths  the  revulsives  act;  the  explana- 
tions of  pathologists  have  not  made  the  question  clear,  and  we  freely  con- 
fess that  we  have  vainly  sought  the  explanation.  The  phenomenon  oc- 
curs spontaneously  during  diseases,  usually  at  the  beginning  or  in  the 
decline,  rarely  at  their  height.  This  may  be  proved,  but  is  as  inexplica- 
ble as  most  other  intimate  organic  acts. 

If  in  the  course  of  one  phlegmasia  another  is  spontaneously  developed, 
while  the  former  disappears,  this  is  considered  by  the  physiological  school 
a  transpositive  revulsion;  for  revulsion  and  metastasis  are  confounded 
by  Broussais.  But  this  pathologist  has  a  sophism  here,  which  relates 
to  the  order  of  appearance  of  phenomena.  Take,  for  examjDle,  the 
parotids. 

We  know  that  the  inflammation  of  this  region  sometimes  removes  to 
the  testicle  or  the  mammary  gland.  If  the  inflammation  in  the  testis  be- 
gan while  the  parotidean  fluxion  was  at  its  height,  and  if  the  latter  did 
not  begin  to  diminish  until  the  former  attained  a  certain  point,  we  might 
well  think  that  here  was  a  case  of  revulsion.  But  remark,  that  the  disap- 
pearance, nearly  or  quite  complete,  of  the  swelling  of  the  parotids,  pre- 
cedes the  pain  and  swelling  of  the  testis.  How  can  this  be  explained  but 
by  something  wholly  different  from  revulsion  ?  and  how  can  we  help  seeing 
tiiat  the  pathologists  were  right  in  separating  revulsion  and  metastasis  ? 
We  easily  admit  that  when  the  metastasis  is  completed  the  new  inflam- 
mation may  exercise  a  transpositive  revulsion  upon  another  phlegmasia, 
or  even  on  the  remnant  of  inflammation  which  lingers  in  the  organ  first 
attacked;  but  we  must  confess  that  the  metastasis  is  the  first  phenome- 
non, the  metastatic  inflammation  the  second,  and  the  transpositive  revul- 
sion the  effect  of  the  latter. 

Leaving  out  the  much  debated  question  of  metastasis,  let  us  suppose 
that  the  spontaneous  phlegmasia  which  acts  as  a  revulsive  antedates  the 
transposition. 

It  is  necessary  next  to  attend  to  what  we  said  above,  to  wit:  that  the 
inflammatory  fluxion  may  persist  after  all  irritation  has  ceased;  in  this 
case  the  slightest  irritation  will  easily  act  as  a  revellent,  in  a  condition 
commonly  supposed  to  be  an  active  inflammation,  but  which  we  shall  not 
explain  any  better. 

From  the  point  of  view  of  the  physiological  school,  and  admitting  that 
the  activity  of  revulsion  is  always  in  proportion  to  the  amount  of  irrita- 
tion, it  will  be  asked  how  an  irritation  can  go  through  all  its  stages,  from 
the  embryo  through  germination,  and  up  to  a  point  of  development  at 
which  it  preponderates  over  others,  wdien  all  the  time  a  powerful  phleg- 
masia exists,  which  ought  easily  to  practise  revulsion  upon  it?  If  it  be 
a  principle  that  a  stronger  irritation  produces  revulsion  upon  a  weaker, 


IRRITANTS    IX    GENERAL.  291 

an  established  phlegmasia  would  never  suffer  another  to  settle  in  the 
system. 

But  we  see  several  phlegmasia  marching  side  by  side,  each  keeping 
its  own  course,  and  modifying  one  another  but  little,  except  in  some  symp- 
toms. Among  morbific  causes  there  are  some  which  produce  disease  in- 
dependently of  any  interior  circumstance.  We  may  see  small-pox  and 
dothinenteritis,  small-pox  and  vaccinia,  and  (in  Bretonneau's  celebrated 
instance)  small-pox,  dothinenteritis  and  dysentery,  each  with  its  specific 
form  and  character.  We  see  that  in  this  case  revulsion  acts  only  upon 
the  inflammatory  fluxion,  not  on  the  disease,  which  will  keep  on  its  way 
at  all  events. 

The  specialty  of  the  causes  of  inflammations  "will  easily  explain  that 
which  the  theories  of  the  Val-de-Grace  left  unexplained,  to  wit,  that  a 
disease  in  which  irritation  plays  at  first  only  a  very  secondary  part  may 
develop  in  the  shadow  of  a  grave  phlegmasia,  and  may  at  last  exceed  the 
former  in  the  severity  of  its  inflammation,  and  may  exercise  a  transposi- 
tive  effect  in  diminishing  it.  We  are  led  to  believe  that  spontaneous 
transpositive  inflammations  are  produced  by  specific  causes,  often  inap- 
preciable, set  in  operation  by  the  primitive  disease;  and  this  is  very  prob- 
ably the  case  with  most  of  the  spontaneous  revulsive  phlegmasife. 

But  a  number  of  spontaneous  phlegmasias,  of  identical  causation,  will 
not  always  act  as  mutual  revulsives.  In  small-pox  the  inflammation  of 
the  skin  of  the  arm,  however  acute  and  intense  it  may  be,  will  never 
have  a  revulsive  effect  on  that  of  the  leg,  for  the  variolous  poison  is  one 
cause  with  a  multiple  effect.  If  we  pass  from  a  cause  with  acute  effects 
to  one  with  chronic  effects,  we  find  that  multiple  syphilitic  phlegmasife  of 
the  gland,  cervix  uteri,  the  bones,  pharynx,  larynx,  skin,  do  not  act  as 
mutual  revulsives. 

This  is  true  as  regards  s^-philis  and  small-pox;  but  the  common  symp- 
toms of  all  local  phlegmasiee,  namely,  the  sanguineous  fluxion,  do  act 
revulsively  upon  one  another  to  some  extent.  For  example,  swelling 
of  the  hands  and  feet  in  variohe  does  make  that  of  the  face  disappear, 
as  the  appearance  of  the  eruption  puts  an  end  to  the  prodromal  symp- 
toms. 

JDuration  of  the  transpositive  revulsion. — The  revulsion  is  divided 
into  mediate  and  immediate;  the  immediate  is  rapidly  ascertained,  often 
in  a  few  minutes.  A  mustard  foot-bath  relieves  a  headache  or  pain  in 
the  throat  at  once;  a  sinapism  relieves  a  superficial  rheumatic  pain  at 
once.  A  large  ammoniacal  blister  suddenly  dissipates  the  orthopnoea 
of  bronchial  catarrh.  These  results  are  so  frequent  as  to  have  put  revul- 
sives in  great  and  deserved  honor.  And  when  less  immediate,  the  results 
may  still  be  remarkably  prompt.  Improvement  often  occurs  in  less  than 
twenty-four  hours,  in  acute  catarrh  after  a  purgative,  in  catarrhal  angina 
after  an  emetic,  and  in  pleurisy  or  pericarditis  after  the  application  of  a 
very  large  blister. 

This  treatment  shows  its  value  at  once;  it  is  important  to  know  this, 


292  THERAPEUTICS. 

for  the  patient's  condition  is  commonly  aggravated  by  persistence  in 
painful  revulsives,  if  after  twelve  or  twenty-four  hours  they  produce  no 
good  result.  They  then  excite  instead  of  transposing,  a  mode  of  action 
which  we  will  study  in  one  of  the  following  chapters. 

The  immediate  revulsion  is  only  applicable  in  acute  disease.  Its  action 
is  essentially  rapid.  We  have  given  the  conditions  under  which  it  is  to 
be  used  in  acute  disease. 

Slow  revulsion  applies  to  chronic  disease;  but  its  action  is  always 
mixed.  As  an  irritant  of  the  skin  it  doubtless  causes  some  fluxion,  but 
its  action  is  far  more  by  spoliation  of  the  elements  of  the  blood  and  deri- 
vative spoliation. 

In  the  next  chapter  we  shall  study  spoliative  treatment  by  itself;  we 
shall  here  regard  it  from  another  point. 

A  copious  supjDuration  has  been  observed  to  bring  on  marasmus,  unless 
the  loss  were  compensated  by  abundant  nutrition.  On  this  fact  spoliative 
treatment  is  founded ;  but  there  is  another  fact,  namely,  that  a  suppura- 
tion, situated  for  example  at  the  upper  part  of  a  limb,  rapidly  causes 
atrophy  of  the  limb,  probably  because  a  part  of  the  arterial  supply  is 
diverted  from  the  limb  to  the  suppurating  spot.  Two  things  are  then  to 
be  considered;  a  local  irritation  which  draws  blood  to  a  part,  and  spoli- 
ation of  the  elements  of  the  blood — that  is,  transpositive  and  spoliative 
revulsion  at  once.  These  two  forms  are  mingled,  for  in  immediate  trans- 
positive  revulsion  the  blood  or  its  elements  are  strongly  attracted  toward 
the  point  of  revulsion,  and  in  the  other  the  elements  of  blood  are  drawn 
and  slowly  poured  out  from  the  system.  There  is  only  this  important 
difference,  that  in  one  case  the  intensity  of  the  irritation  is  the  lead- 
ing phenomenon;  in  the  other  it  is  the  abundance  of  spoliation.  Hence 
spring  naturally  the  rules  which  should  direct  us  in  the  choice  of  revul- 
sives. For  the  most  acute  and  rapid  diseases,  take  revulsives  that  act 
directly;  for  congestions,  take  mustard,  caloric,  urtication,  flagellation, 
cupping.  To  recall  eruptions  to  the  skin  use  the  same,  but  longer.  For 
acute  energetic  phlegmasia^,  ammonia  and  cantharides.  For  chronic  affec- 
tions take  antimonial  ointment,  the  permanent  blister,  and  especially  the 
issue  or  seton.  Atrophy  of  limbs  caused  by  morbid  or  therapeutic 
suppurations  upon  them  leads  to  the  use  of  cauteries  and  setons  not  only 
for  resolving  chronic  engorgements,  but  also  to  produce  atrophy  of  the 
tissues  in  which  excessive  nutrition  exists.  Thus,  issues  and  setons  over 
the  regions  of  the  heart,  the  liver,  the  spleen,  to  modify  the  nutrition  of 
these  organs  if  hypertrophied. 

When  the  transpositives  are  used,  the  duration  of  the  symptoms  they 
are  directed  against  must  be  carefully  estimated,  to  save  the  patient  from 
needless  pain  and  perhaps  dangerous  therapeutic  effects.  We  will  give, 
as  an  example,  cholera.  The  indication  for  revulsives  hardly  exists  in 
cholera  except  during  the  cold  period;  the  life  which  seems  about  to  fade 
away  must  be  recalled  to  the  skin  at  any  rate,  and  the  means  of  cutane- 
ous stimulation  cannot  be  too  manv.     Whether  the  irritants  act  as  gen- 


IRRITANTS    IN    GENERAL.  293 

eral  excitants,  or  as  transposing-  to  the  skin  tlie  internal  fluxion  whicli  is 
supposed  to  attack  the  digestive  organs,  in  either  case,  the  indication  for 
revulsives  exists  only  in  the  cold  stage;  as  soon  as  reaction  begins,  far 
from  seeking  to  increase  the  points  of  inflammation,  we  must  do  our  best 
to  extinguish  them  where  they  appear.  In  irritating  the  skin  during  the 
Hrst  period,  we  are  obliged  to  look  for  methods  of  sufficient  energy,  and 
yet  of  such  a  transitory  nature  that  they  leave  no  traces  during  the  second 
period.  Urtication  and  mustard  do  this  admirably;  if  blisters  with  am- 
monia or  cantharides  could  produce  the  same  results  at  once,  thev  would 
still  compromise  the  patient's  safety  subsequently  by  the  excess  of  fever 
tliey  provoke.  We  have  taken  cholera  as  a  type,  but  there  are  few  dis- 
eases in  which  we  do  not  sometimes  have  to  do  the  same.  At  the  onset 
•of  an  acute  disease,  if  the  blood,  which  is  so  important  in  most  affections, 
is  only  in  the  condition  of  congestion,  a  rubefacient  is  indicated;  a  topi- 
cal agent  which  might  cause  a  continued  inflammation  is  to  be  feared,  for 
it  may  become  a  source  of  prolonged  and  needless  sufi'ering,  or  perhaps 
of  general  excitation.  The  same  rule  should  be  observed  when  we  have 
gi'ound  to  suppose  that  we  shall  have  to  continue  this  treatment  several 
■days,  for  one  may  safely  place  ten  sinapisms  a  day  on  a  patient's  body, 
but  not  that  number  of  blisters  or  issues.  In  general,  the  revulsive 
irritatives  should  be  limited  in  extent,  in  proportion  as  the}^  are  ener- 
getic. 

Place  for  revulsion. — For  this  purpose  we  should  choose  a  tissue  in 
which  the  artificial  malady  will  not  be  more  severe  or  troublesome  than 
the  one  we  are  combating.  Experience  points  to  the  skin  and  mucous 
membrane  as  those  which  best  endure  irritations.  The  systematic  state- 
ments of  Broussais  concerning  the  pathological  and  physiological  supre- 
macy of  the  stomach  and  intestines  have  only  been  accepted  by  those  ig- 
norant of  experimental  pathology  and  physiology.  When  we  compare 
the  structure  and  functions  of  these  two  membranes,  we  find  that  if  a 
prompt  irritation  and  a  rapid  and  abundant  secretory  evacuation  are  re- 
quired we  must  address  the  mucous  membrane.  Thus,  in  angina,  in  pul- 
monary catarrh,  in  certg,in  superficial  cutaneous  afiiections  which  mav 
safely  be  caused  to  disappear,  an  emetic  or  purgative  will  act  with  more 
benefit  than  any  irritant  applied  to  the  skin;  and  this  is  readily  under- 
stood when  we  think  of  the  immense  surface  of  mucous  inembrane  and 
the  abundance  of  the  secretion  which  the  contact  of  an  irritant  produces. 
If  we  require  a  transient  and  superficial  irritation,  to  be  renewed  every 
day,  the  intestinal  canal  should  always  be  preferred  to  the  skin;  thus,  in 
chronic  headaches,  in  frequently  occurring  congestions  of  the  brain  or 
lungs,  in  chronic  ophthalmia,  no  revulsion  takes  the  place  of  a  dailv 
purge.  But  if  we  require  a  deeper  and  more  continued  irritation,  we 
must  appeal  to  a  membrane  wliose  functions  are  not  so  essentially  related 
to  nutrition,  namely,  the  skin.  With  the  invasion  of  the  physiological 
doctrine,  revulsives  to  the  intestinal  canal  were  banished  from  therapeu- 
tics, and  the  skin  alone  had  to  bear  the  burden  of  all  inflammations;   but 


294  THEEAPEUTICS. 

within  a  certain  number  of  years  the  purgatives  have  been  properly  re- 
sumed. 

A  suppurative  inflammation  may  be  situated  in  the  skin  for  a  life- 
time without  doing  any  harm  to  the  system;  it  ought,  therefore,  to  be 
selected  for  all  very  protracted  revulsion.  Besides,  we  may  choose  what 
portion  of  skin  we  will;  whereas  if  we  use  the  digestive  tract,  we  must 
irritate  the  whole  of  it,  unless  we  make  rectal  injections. 

There  is  nothing  exact  in  regard  to  the  portions  of  skin  or  mucous 
membrane  which  we  ought  to  prefer;  but  some  general  rules  may  be 
given,  as  follows. 

Experience  shows,  though  it  may  not  be  easy  to  explain  the  fact,  that 
certain  parts  of  the  body  are  connected  with  other  distant  parts  by  func- 
tional ties  which  may  properly  be  called  sympathies.  These  are  infinitely 
less  in  number  than  Broussais  and  other  solidists  pretend,  but  some  such 
do  exist.  The  Avomb  and  the  breasts,  which  are  physiologically  con- 
nected, have  also  a  pathological  sympathy;  whence  the  precept  of  Hip- 
pocrates, to  apply  cups  to  the  breasts  of  women  affected  with  metror- 
rhagia; and  the  general  principle  of  soliciting  blood  to  the  uterus  in  wo- 
men threatened  with  scirrhus  or  cancer  of  the  mammary  glands. 

The  suppression  of  certain  fluxes,  certain  fluxions,  or  certain  morbific 
accidents,  as  rheumatism,  gout,  etc.,  is  a  frequent  cause  of  disease.  The 
aim  of  the  therapeutician  should  be  to  recall  these,  by  revulsives,  to  their 
former  places. 

It  is  manifest  that  when  an  habitual  epistaxis  or  a  chronic  coryza  is 
succeeded  by  an  obstinate  headache  or  a  laryngeal  catarrh,  the  treatment 
must  produce  a  new  irritation  in  the  mucous  membrane  of  the  nasal  fossce 
by  the  use  of  mercurial  powders,  hellebore,  etc.;  and  if  the  discharge 
from  piles  is  suppressed,  and  replaced  by  symptoms  which  seem  caused 
by  such  suppression,  the  best  revulsives  will  be  antimonial  suppositories 
and  cups  to  the  margin  of  the  anus;  and  warm  or  sinapized  foot-baths, 
cups  to  the  thighs,  and  sitz-baths,  to  recall  the  menstrual  flow,  in  case 
suppression  causes  alarming  symptoms. 

The  suppression  of  one  disease  sometimes  gives  rise  to  another  that  is 
worse,  as  in  the  case  of  piles  or  coryza;  we  ought  then  to  prefer  the  light 
affection  to  the  severe,  and  to  do  everything  to  re-establish  the  former, 
but  the  patient  often  wishes  to  get  rid  of  both.  We  have  known  a  young 
woman  troubled  with  leucorrhoea  and  engorgement  of  the  womb  for  years; 
she  wished  to  be  cured;  but  as  soon  as  the  uterine  flow  disappeared,  she 
was  troubled  with  haemoptysis  and  all  the  signs  of  incipient  tubercle  of 
the  lungs.  Fortunately,  she  had  a  miscarriage  which  brought  back  the 
uterine  flow  and  the  leucorrhoea;  and  all  the  morbid  symptoms  connected 
Avith  the  lungs  soon  ceased.  She  then  applied  to  us  to  be  cured  of  her 
leucorrhoea,  but  we  positively  refused  to  do  anything  until  she  allowed 
a  large  issue  to  be  placed  upon  her  arm.  The  issue  was  applied,  the  ute- 
rine affection  was  readily  cured,  and  the  trouble  with  the  lungs  did  not 
return. 


IRRITANTS    IN    GENERAL.  295 

AVhen  the  cure  of  a  chronic  phlegmasia  gives  rise  to  grave  symptoms, 
we  must  either  re-establish  the  former  affection,  or  at  least  fill  its  place  by 
topical  agents  which  maintain  at  one  point  of  the  skin  a  permanent  in- 
flammation and  an  abundant  suppuration;  and  here  the  blisters,  issues 
and  setons  play  the  chief  part. 

As  regards  the  most  suitable  place  for  applying  revulsion,  in  given 
cases  of  disease,  the  practice  is  so  contradictory  and  the  observations  are 
so  few  that  we  shall  take  the  part  of  simple  narrators,  and  refrain  from 
an  expression  of  opinion. 

Some,  for  example,  for  irritant  affections  of  the  brain,  direct  mustard 
foot-baths  and  blisters  to  the  legs;  others  apply  cups,  blisters,  setons  or 
moxas  to  the  nucha  to  satisfy  the  same  indication.  Some,  in  acute  or 
chronic  thoracic  inflammation,  prefer  revulsion  by  the  walls  of  the  chest; 
others  prefer  to  irritate  the  skin  of  the  arms  and  legs.  Some,  in  engorge- 
ments of  the  liver,  irritate  the  mucous  membrane  of  the  digestive  tract  as 
much  as  they  can,  and  chiefly  the  lower  part  of  the  rectum;  others  pro- 
scribe these  methods,  and  direct  revulsives  to  the  skin  and  cellular  tissue 
of  the  right  hypochondrium.  Some  make  it  an  invariable  rule  to  place 
the  revulsive  between  the  heart  and  the  affected  point,  so  as  to  intercept 
the  circulation  and  draw  off  the  blood  or  some  of  its  elements  before  it 
reaches  the  inflamed  tissue.  It  would  be  hard  for  us  to  say  whether 
these  rules  are  founded  in  reason;  experience  must  be  the  judge  in  such 
cases.  Usage,  which  perhaps  is  not  the  best  rule,  generally  directs  that 
in  order  to  cure  congestions,  we  should  apply  the  excitant  to  a  part 
which  receives  a  different  blood-supply  from  that  which  is  distributed  to 
the  congested  part.  To  solicit  congestion  of  the  uterus,  which  is  supplied 
by  a  division  of  the  iliac  artery,  we  apply  to  the  legs  topical  irritants 
capable  of  drawing  to  the  capillary  extremities  of  the  femoral  artery; 
which  like  the  hypogastric  is  only  a  division  of  the  iliac;  while  on  the 
contrary,  we  use  exactly  the  same  means  to  avert  congestion  of  the  brain, 
which  is  supplied  from  the  carotid  and  the  subclavian.  The  mobility  of 
the  blood,  when  congestion  only  exists,  renders  this  distant  effect  easy; 
but  when  a  phlegmasia  is  commencing,  or  the  inflammation  is  beginning 
to  fail,  the  transpository  irritants  must  be  placed  in  contact  with  the 
skin  near  the  affected  region.  It  is  the  same  with  spoliative  treatment, 
unless  our  object  be  to  bring  back  a  fluxion  to  a  point  whence  it  has 
disappeared;  thus,  when  the  healing  of  an  ulcer  on  the  legs  is  followed 
by  a  chronic  phlegmasia  of  the  thoracic  organs,  it  is  better  not  to  put 
an  issue  or  a  seton  in  the  walls  of  the  chest,  but  to  make  an  issue 
in  the  leg  where  the  ulcer  was,  or  to  make  the  old  sore  suppurate  with  a 
permanent  blister. 

The  seat  of  revulsion  is  most  important  to  decide  when  we  wish  to 
produce  atrophy  of  an  organ,  or  at  least  to  arrest  the  excess  of  nutrition, 
which  may  soon  occasion  functional  trouble.  Thus,  when  iodine  fails  to 
cure  hypertrophic  goitre,  the  forming  of  an  issue  over  the  tumor  is  per- 
haps the  simplest   remedy,  as  in  simple   hypertrophy   of   the  heart  it  is 


296  THERAPEUTICS. 

useful  to  keep  up  large  surfaces  of  the  suppuration  on   the  skin  of  the 
praecordial  region. 

One  Avord  more.  Do  all  these  facts,  verified  as  they  are  by  medical 
tradition,  find  an  explanation  in  modern  physiology  ?  Must  we  admit, 
for  instance,  that  reflex  action  gives  a  sufficient  account  of  them?  It  is 
certain  that  some  substances  which  do  not  change  the  coarse  structure 
of  tissues  to  which  they  are  applied  may  produce  in  the  deep-seated 
organs,  by  reflex  action,  important  and  perhaps  even  permanent  modifi- 
cations; but  the  case  is  quite  different  with  revulsion. 

In  revulsion  we  produce  at  a  point  a  more  or  less  permanent  lesion, 
and  not  a  transitory  effect,  as  when  we  wish  for  a  reflex  action;  besides, 
in  order  that  the  reflex  action  may  be  active,  it  is  necessary  that  the 
spinal  cord  be  separated  from  the  brain,  etc.  Yet  we  do  not  deny  that 
in  revulsion  reflex  actions  occur;  what  we  do  deny  is,  that  revulsion  is 
accomplished  simply  through  a  reflex  action. 

We  believe  that  the  theory  of  revulsion  is  to  be  derived  entirelv  from 
the  application  to  biology  of  that  great  discovery  of  the  unity  of  ph^'sical 
force,  and  of  the  equivalent  transformations  of  its  different  modes;  of 
which  discovery,  the  determination  of  the  mechanical  equivalent  of  heat 
is  but  a  fragment. 

Man  has  only  two  sources  from  which  to  draw  the  force  which  he  re- 
quires, food  and  respiration;  he  expends  it  in  muscular  labor,  secretion, 
mental  labor,  etc.  The  difference  between  these  two  terms  represents 
growth  and  excretion.  In  the  total  of  expended  force,  the  modes  of  ex- 
penditure vary  with  the  nature  of  the  life;  one  expends  more  in  intel- 
lectual labor,  another  in  mechanical  toil,  a  nurse  in  lacteal  secretion,  etc. 

It  is  very  prolmbly  the  same  in  pathology.  In  a  given  affection,  one 
element  will  assume  a  leading  importance,  and  the  morbid  labor  may  at  a 
given  moment  undergo  a  total  transformation  into  another  equivalent 
form  of  labor.  We  consider  this  the  true  scientific  formula  of  crisis  of 
metastasis,  and,  in  particular,  of  revulsion.  We  may  perhaps  say  that  re- 
vulsion or  derivation  consists  in  establishing  upon  an  organ  of  minor  im- 
portance an  artificial  action  which  is  without  danger  to  the  system,  to  re- 
place the  morbid  action;  that  is,  to  form  its  equivalent. 

Choice  of  revulsives. — Experience  gives  us  the  law,  that  in  order  to 
produce  a  good  revulsion,  we  must  as  far  as  possible  establish  an  artificial 
pathological  action  of  the  same  nature  as  that  of  the  disease  we  wish  to 
attack.  To  congestion  we  oppose  rubefacients;  to  exudative  phleonui- 
sifB,  blisters  aiid  the  irritants  which  produce  exudation;  to  suppurations, 
revulsives  which  produce  pustulation,  and  issues. 


Spoliative  Irritant  Treatment. 

Spoliation,  in  the  therapeutical  sense,  occurs  whenever  one  or  more 
of  the  elements  of  the  blood  are  withdrawn  from  it,  in  a  greater  propor- 


IKRITANTS    IN    GENERAL.  297 

tion  than  is  due  to  the  normal  processes  of  organic  composition  and  de- 
composition. 

The  abnormal  secretions  are  merely  exaggerations  of  the  regular  se- 
cretions of  the  economy,  and  spoliative  treatment  is  applied  solely  through 
the  excretions.  The  secretion  of  pus  is  doubtless  more  than  an  exaggerated 
normal  secretion;  but  in  any  case,  it  is  always  one  or  more  of  the  elements 
of  the  blood  that  are  secreted. 

Ptyalism,  diarrhoea,  bilious  or  mucous  vomiting,  the  various  catarrhs, 
diaphoresis,  diuresis,  are  the  agents  of  spoliation.  We  shall  speak  at  a 
later  time  of  evacuants,  that  is,  agents  which  increase  the  secretion  of 
the  alimentary  mucous  membrane  and  its  appendages;  and  of  antiphlogis- 
tic treatment,  in  which  spoliation  by  the  direct  evacuation  of  blood-ves- 
sels is  the  chief  feature;  of  diuretics,  sudorifics,  etc.  We  shall  here  speak 
of  only  a  portion  of  spoliative  medicine,  that  which  acts  through  suppu- 
ration. 

Chemical  analysis  has  demonstrated  serum,  albumin  and  fibrin  in  a 
new  state  of  combination  in  the  pus;  from  which  it  follows  that  suppura- 
tion necessarily  draws  from  the  system  all  the  principles  of  the  blood  ex- 
cept one,  the  cruor. 

Omitting  for  the  moment  the  local  and  sympathetic  irritation  which 
necessarily  accompany  suppui'ation,  we  will  study  first  the  isolated  fact  of 
spoliation. 

If  most  of  the  elements  of  the  blood  are  used  without  profit  to  nutri- 
tion, daily  and  momentarily,  the  expenditure  must  be  out  of  proportion 
to  repair,  and  the  organs  will  have  a  tendency  to  atrophy.  This  is  what 
occurs  after  all  abundant  suppuration;  and  marasmus  is  the  necessary 
consequence.  The  diminution  of  the  blood  in  the  vascular  channels  must, 
and  always  does  produce  this  effect.  Physiological  experiments  show 
that  bloodletting  singularly  assists  absorption;  now  a  partial  and  conti- 
nued bloodletting,  like  suppuration,  produces  the  same  result,  but  slowly 
and  insensibly. 

Resolution  in  phlegmasias  is  simply  interstitial  resorption  in  a  special 
organ,  as  emaciation  is  interstitial  resorption  in  all  the  tissues  of  the 
economy. 

We  will  here  give  a  brief  attention  to  certain  phenomena  of  secretion 
in  inflamed  organs. 

In  the  first  stage  of  inflammation  there  occurs  an  active  flow  of  liquid 
to  the  part:  after  which,  the  interstitial  secretion  increases,  and,  in  cer- 
tain organs,  attains  an  extraordinary  abundance.  This  abundance  is 
nowhere  more  considerable  than  in  the  large  and  small  cellular  cavities, 
as  the  serous  sacs  and  the  cellular  tissue  proper.  In  parenchyma  which 
has  a  degree  of  resemblance  to  cellular  tissue,  as  the  lung,  the  morbid  in- 
terstitial secretion  is  almost  as  great  as  in  the  cellular  tissues  proper. 

While  the  cause  of  inflariimatory  fluxion — the  irritation — persists,  the 
fluxion  itself  is  always  in  excess  of  absorption,  and  the  swelling  keeps  in- 
creasing;   but  when  irritation  ceases,  and  the  general  harmony  of    the 


298  THERAPEUTICS. 

forces  is  re-established,  resorption  occurs  with  a  rapidity  proportioned  to 
the  number  and  vascularity  of  the  cavities  in  which  it  is  contained,  and 
the  abundance  of  the  secretion.  Hunger  is  a  most  certain  sign  of  the  ac- 
tivity of  interstitial  resorption;  when  convalescents  are  hungry,  absorp' 
tion  is  going  on  with  unusual  intensity  in  the  tissues  which  have  just  been 
the  seat  of  phlegmasia. 

It  is  at  first  hard  to  see  why  interstitial  absorption  goes  on  with  prodi- 
gious activity  in  a  lung  which  has  lately  been  inflamed,  while  it  is  null  or 
almost  null  in  the  healthy  tissues,  the  muscles,  liver,  spleen,  kidneys,  etc. 
It  is  because  the  blood,  when  once  converted  into  a  framework  or  a 
parenchyma,  lives  a  more  energetic,  complete,  and  individual  life,  and  as 
a  living  body  gains  the  power  of  resisting  the  absorbent  action  of  the 
vessels;  while  fluids  exuded  in  the  cellular  tissue  possess  but  an  incom- 
plete organization,  and  have  only  the  life  of  organic  molecules;  they  have 
the  faculty  of  becoming  tissues — but  as  yet,  no  individual  existence. 
They  are  therefore  the  first  to  be  attacked  by  the  interstitial  digestive 
forces,  as  are  the  alimentary  substances  in  the  digestive  tubes. 

A  constant  suppuration  at  one  point  of  the  body,  by  causing  a  constant 
depletion  of  the  sanguine  system,  continually  starves  the  organs  of  absorp- 
tion (if  we  may  use  the  expression),  and  consequently  favors  the  resolution 
of  effused  inflammatory  products. 

Whenever  a  chronic  phlegmasia  exists  at  any  point  of  the  body,  and 
irritation  has  nearly  or  quite  ceased,  while  the  morbid  effusions  remain 
in  the  serous  cavities,  or  in  the  parenchyma;  or  when  the  products  are 
effused  externally  as  in  the  case  of  the  mucous  membranes  and  the  skin, 
it  is  the  physician's  duty  to  establish  a  point  of  suppuration,  if  he  has  not 
obtained  a  cure  by  the  ordinary  means. 

Spoliation  by  exutories,  however  continuous,  is  not  so  active  that  it 
can  balance  the  restitution  made  by  a  rich  alimentation  which  furnishes 
more  than  the  system  needs.  The  patient,  therefore,  while  spoliative 
treatment  is  continued,  must  be  subjected  to  such  a  regimen  that  repair  is 
below  the  requirements,  in  order  that  the  exutory  may  not  lose  its  activ- 
ity. It  does  not  follow  that  we  must  always  restrict  the  diet  where  an 
exutory  is  applied.  Dieting,  or  at  least  a  somewhat  severe  regimen,  is 
necessary  so  long  as  morbid  products  remain  to  be  absorbed;  but  after- 
wards the  severity  of  the  regimen  may  be  relaxed,  as  the  exutory  no 
longer  needs  to  act  by  spoliation,  but  by  other  properties  of  which  we 
will  speak  hereafter. 

There  is  a  very  grave  question  in  medicine,  which  has  for  centuries 
been  considered  as  settled,  and  which  is  hardly  discussed  at  present  by 
pathologists;  it  is  the  question  of  the  spoliation  of  certain  degenerated 
humors  by  exutories.  At  the  time  when  pathology  was  ruled  by  the 
idea  of  the  humors,  it  was  firmly  believed  that  the  exutory  acted  only  by 
removing  the  peccant  material  from  the  blood;  a  depurative  action. 
Such  an  opinion  had  the  advantage  of  striking  with  a  material  fact;  the 
vulgar,  and  the  doctors  too,  who  cannot  always  be  distinguished  from  the 


IRRITANTS    IN    GENERAL.  299 

vulgar,  were  the  more  convinced  of  depuration,  as  they  saw  it  proved  by 
the  senses.  For  more  than  sixty  years  the  solidist  doctrines  have  gov- 
erned the  medical  art  in  their  turn,  and  yet  physicians  hardly  dare  to 
brush  against  a  popular  view  which  is  so  profoundly  rooted  and  so  vig- 
orous. 

Certainly  no  one  will  suspect  us  of  wishing  to  revive  absurd  humoral 
notions,  or  to  wish  to  revive  the  question,  whether  the  pus  discharged  by 
a  seton  existed  before  the  match  was  applied;  but  there  is  an  element  of 
truth  in  the  pretended  depuration,  which  we  will  state. 

To  make  ourselves  clear,  we  will  recall  a  fact  which  has  certainly  been 
noticed  a  thousand  times  by  physicians,  and  to  which  Bretonneau  was 
the  first  to  call  the  attention  of  pathologists.  A  man  may  for  years  re- 
ceive slight  wounds  with  impunity,  and  even  very  deep  wounds,  without 
suppuration  ever  appearing;  everything  unites  most  readily  by  first  in- 
tention. He  has  what  may  be  called  a  healthy  skin.  But  if  by  chance 
he  receives  an  injury  of  such  a  nature  that  suppuration  is  a  necessary 
consequence,  he  will  subsequently,  and  perhaps  for  a  great  many  years, 
suppurate  on  the  slightest  occasion,  and  will  have  what  is  called  "  a  pois- 
onous skin,"  that  is,  a  skin  which  is  poisoned  very  easily  by  wounds,  even 
if  slight.  Furuncular  eruptions,  anthrax,  phlegmasias  of  bad  character, 
will  be  often  observed  in  him,  and  frank  inflammation,  even  of  the  inter- 
nal organs,  will  pass  into  suppuration  more  readily  than  in  other  patients. 

It  is  also  observed  that  patients  who  wear  an  issue  or  a  seton  do  not 
suffer  from  the  troubles  just  named  while  the  suppuration  is  kept  up; 
but  that  the  troubles  appear  at  the  moment  the  flow  of  pus  is  suspended, 
to  disappear  again  when  the  exutory  is  re-established.  Further,  in  per- 
sons thus  disposed  to  suppuration,  issues  and  setons  give  a  much  more 
abundant  discharge  of  pus  than  in  other  persons. 

Is  it,  then,  absurd  to  claim  that  the  blood  contains,  if  not  pus,  at 
least  elements  which  will  turn  to  pus  with  deplorable  readiness;  and  that 
the  irritation  caused  by  the  pea  of  an  issue,  or  the  string  of  a  seton,  in 
calling  an  inflammatory  fluxion  to  a  given  point,  attracts  towards  that 
point  the  molecules  of  blood  which  have  a  tendency  to  become  pus,  and 
exhausts  (if  we  may  so  speak)  the  purulent  leaven  of  the  blood  ?  In  this 
point  of  view  an  exutory  is  a  real  depurative  agent,  in  the  sense  in  which 
the  physicians  of  old  time  understood  it. 

Let  us  pass  by  the  explanation,  and  come  to  the  practical  result.  If 
by  the  aid  of  an  actively  sustained  exutory  we  put  an  end  to  the  disposi- 
tion to  suppurate,  we  also  lessen  the  chances  of  all  diseases  of  a  bad  type, 
of  those  parenchymatous  suppurations  which  are  so  destructive,  and  so 
ready  to  appear,  in  the  condition  of  which  we  now  speak.  The  exutories 
will  in  this  case  be  ordered  rather  as  a  prophylactic  than  as  a  remedy. 

On  the  other  hand,  if  the  suppression  of  an  issue,  a  blister  or  a  seton 
causes  a  general  tendency  to  suppuration,  we  must  be  more  cautious  than 
is  generally  the  case  in  ordering  the  suppression  of  the  suppuration,  or  must 
take  the  precautions  which  our  predecessors  have  so  much  insisted  upon. 


300  THERAPECTTICS. 

It  is  easy  to  see  how  grave  a  matter  may  be  the  suppression  of  an 
exutory  which  has  been  worn  a  long  time.  First,  the  system  is  accus- 
tomed, and  with  benefit,  to  the  secretory  servitude.  The  morbid  secre- 
tion has  become  constitutional,  and  therefore  cannot  be  suppressed  with- 
out a  great  general  perturbation;  and  besides,  the  system  retains  for  a 
lono-  time  a  tendency  to  suppurate  which  has  its  dangers  in  case  a 
phlegmasia  should  occur. 

From  what  we  have  said  it  does  not  follow  that  we  regard  exutories 
as  indispensable  in  the  treatment  of  all  chronic  phlegmasias,  and  after  all 
suppurations,  and  that  we  never  permit  their  suppression.  We  only 
wish  to  say  that  exutories  must  always  be  replaced  by  other  spoliative 
agencies,  at  the  head  of  which  we  put  purgatives,  sudorifics  and  diure- 
tics. The  long-repeated  use  of  these  is  a  powerful  method  of  diversion, 
and  if  our  predecessors  have  prescribed  them  to  excess,  they  have  been 
proscribed  in  our  day  with  a  rigor  which  is  not  justihed  by  the  former 
abuse. 

The  choice  of  an  exutory  is  not  indifferent.  Our  sole  aim  is  to  with- 
draw a  portion  of  most  of  the  principles  of  the  blood.  The  local  irrita- 
tion, a  necessary  condition  of  suppuration,  must  be  as  slight  as  possible; 
of  all  methods,  the  issue  is  certainly  the  least  painful;  the  seton  comes 
next,  which  gives  a  little  more  jiain,  but  by  the  abundance  of  its  discharge 
causes  a  very  abundant  humoral  evacuation.  The  seton  may,  therefore,  be 
preferred  as  a  remedy,  and' the  issue  as  a  prophylactic.  We  must  use  the 
seton  in  chronic  visceral  phlegmasias,  in  inflammations  of  the  mucous  lin- 
ing of  the  great  splanchnic  cavities.  As  to  blisters,  the  sharp  pain  which 
they  almost  always  occasion,  the  difficulty  of  dressing  them,  and  the  ine- 
quality of  the  suppuration,  ought  to  cause  their  disuse  as  general  spolia- 
tive agents,  though  they  form  an  heroic  remedy  to  fulfil  the  other  indica- 
tions of  irritant  treatment. 

We  have  passed  over  the  local  and  sympathetic  irritation  provoked  by 
an  exutory,  independently  of  spoliation;  but  this  part  must  not  be  neg- 
lected. For  there  is  a  double,  and  sometimes  a  triple  therapeutic  action, 
to  wit:  a  transpositive,  an  excitative,  and  a  spoliative  action.  We  have 
already  stated  our  view  of  transpositive  treatment;  and  shall  next  at- 
tempt to  explain  under  what  circumstances  irritation  of  the  skin  be- 
comes a  cause  of  general  excitation. 

If  we  pass  in  review  the  spoliative  agents,  we  shall  find  that  the  exuto- 
ries are  the  least  injurious  of  all.  It  is  doubtless  convenient  to  purge,  to 
produce  sweating  or  diuresis;  but  as  these  results  are  always  obtained 
by  an  irritation  applied  to  a  large  surface,  or  an  active  modification  of  the 
entire  economy,  the  organs  do  not  always  get  accustomed  to  this  continu- 
ous perturbation,  but  may  become  fatigued  or  inflamed,  or  lose  their  irri- 
tability, and  a  too-dearly  bought  treatment  has  to  be  abandoned.  Of 
small  daily  bleedings  it  is  impossible  to  think  seriously,  though  it  has  been 
advised  by  the  exaggerated  and  rash  partisans  of  the  physiological  doc' 
trine. 


IKKITANTS    IN    GENEKAL.  301 

But  the  application  of  an  exutory,  considered  as  a  local  irritation,  is 
rarely  dangerous,  even  in  the  slightest  degree;  except  in  persons  so  exci- 
table that  they  could  not  endure  any  other  spoliative  remedy.  Con- 
sidered as  a  spoliative,  the  exutory,  by  the  slowness  and  the  continuity  of 
its  action,  and  the  ease  with  which  its  effects  can  be  measured  and  grad- 
uated, will  always  hold  the  first  rank  among  the  agents  of  sjDoiiative 
treatment. 

Excitative  Treatment. 

We  have  seen  topical  irritants  applied  to  the  human  body  for  the  pur- 
pose of  substituting  a  therapeutical  inflammation  for  one  already  existing, 
or  in  order  to  carry  to  a  given  point  a  phlegmasia  existing  in  another 
place,  or  to  solicit  a  continued  flow  of  the  elements  of  the  blood  and  a 
kind  of  derivation. 

We  have  said  that  these  attempts  are  often  mixed,  and  can  never  be 
obtained  perfectly  isolated.  There  is  a  fourth  mode  of  action,  which  is 
hardly  distinguished  from  the  two  preceding,  but  which,  like  them,  ac- 
quires a  special  predominance  under  some  circumstances. 

The  local  irritants,  as  giving  rise  to  an  inflammation,  produce  the 
consequences  of  all  inflammations,  to  wit,  a  local  fever  always,  and 
sometimes  a  local  and  a  general  fever  at  once. 

The  reaction  of  the  system  against  morbific  agents,  called  fever,  is  a 
necessary  and  often  useful  incident  of  almost  all  acute  diseases. 

It  may  sometimes  be  beneficial  to  excite  fever,  and  there  will  often  be 
many  advantages  in  preferring  an  irritant  applied  to  the  skin  rather  than 
an  excitant  which  acts  by  absorption.  We  do  not  share  the  belief,  which 
of  late  has  prevailed  too  widely,  that  these  excitants  are  dangerous,  owing 
to  the  gastritis  and  the  gastro-enteritis  which  they  occasion.  It  would 
in  truth  be  hard  to  find  among  the  excitants  any  agent  which  might  be 
considered  as  a  topical  irritant  in  prudent  doses.  These  puerile  fears  do 
not  stand  in  our  way;  but  experience  shows  that  the  remedies  which 
enter  by  absorption  do  not  always  have  as  simple  a  mode  of  action  as 
those  which  appeal  to  the  nervous  system  alone,  doubtless  because  they 
are  carried  by  the  circulation  to  stimulate  all  the  blood-containing  organs, 
together  with  the  nervous  centres.  The  cutaneous  irritants  evidently 
act  on  the  nervous  system  alone,  and  in  this  respect  are  closely  allied  to 
caloric.  Thus,  when  the  Brownian  excitability  seems  extinct,  and  when, 
febrile  reaction  diminishing,  the  other  symptoms  become  aggravated,  we 
must  employ  sinapisms,  flying  blisters,  and  the  various  irritant  applica- 
tions almost  exclusively. 

We  have,  in  speaking  of  cholera,  remarked  upon  the  harmfulness  of 
exaggerating  this  excitation.  It  may  be  considered  a  rule,  that  if,  from 
experience,  we  judge  that  excitation  will  be  long  required,  blisters  must 
be  preferred.  But  when  we  require  only  a  transient  excitation,  as  in  the 
cold  period  of  cholera,  in  the  period  of  concentration  of  pernicious  inter- 


302  THEE  APEUTICS. 

mittents,  the  only  remedies  indicated  are  urtication,  mustard  poultices, 
the  use  of  heat  as  a  rubefacient,  or,  in  brief,  the  energetic  and  transitory 
agents. 

If  these  acted  only  as  excitants,  they  would  nevertheless  find  employ- 
ment in  a  great  variety  of  circumstances;  but  they  possess  in  addition  im- 
portant revulsive  and  spoliative  powers,  whei-eby  they  fulfil  a  triple  indi- 
cation, which  excitants  given  internally  never  could.  These  manifold 
powers  are  found  also  in  topical  irritants  applied  to  a  small  surface,  with 
the  object  of  causing  a  local  excitation.  The  latter  can  never  be  pro- 
duced except  by  topical  means,  for  it  would  be  an  inconvenient  thing  to 
arouse  the  whole  system  in  order  to  reach  a  corner  of  the  body,  which  we 
should  probably  rarely  reach  after  all.     A  few  words  will  explain  it. 

The  fact  of  inflammation  in  a  region  excites  a  fluxion  of  blood  and  an 
effusion  of  morbid  pi'oducts  into  the  meshes  of  the  tissue,  or  upon  the 
surface  of  membranes.  When  the  inflammation  has  lasted  some  time,  the 
local  incitability  becomes  lessened,  and  the  interstitial  energy  necessary 
to  the  digestion  and  assimilation  of  morbid  products  is  no  longer  ade- 
quate to  such  result.  In  the  same  way,  in  a  stomach  weakened  by  too 
exciting  a  diet,  the  food  cannot  be  digested  unless  the  excitation  be  in- 
creased; and  likewise,  in  a  tissue  whose  incitability  has  been  used  up  by 
excess  of  irritation,  the  effused  morbid  products  will  not  be  absorbed 
unless  we  stimulate  the  vital  properties  of  the  part.  This  explains  the 
success  of  blisters,  of  issues,  of  the  objective  cautery,  of  the  moxa,  in  in- 
dolent tumors;  an  explanation  which  would  not  be  completely  satisfac- 
tory if  we  did  not  attend  to  the  transpositive  and  spoliative  actions  which 
occur  at  the  same  time. 

In  this,  as  in  all  treatment,  excess  should  be  avoided;  for,  if  it  be 
necessary  to  excite  the  vital  properties,  the  stimulation  must  not  be 
pushed  so  far  as  to  cause  too  energetic  an  inflammation;  not  that  this  may 
not  sometimes  be  useful,  as  a  substitutive;  but  in  general  the  action  of  the 
local  remedies  must  be  graduated  so  as  to  solicit  at  most  a  slight  inflam- 
mation which  is  directly  relieved  by  antiphlogistics. 


End  of  Volume  I. 


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